Provider Demographics
NPI:1033524749
Name:MACCONNELL, MAUREEN (APNP)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:MACCONNELL
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LAKE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-6785
Mailing Address - Country:US
Mailing Address - Phone:715-848-4600
Mailing Address - Fax:715-845-5398
Practice Address - Street 1:1100 LAKE VIEW DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-6785
Practice Address - Country:US
Practice Address - Phone:715-848-4600
Practice Address - Fax:715-845-5398
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT200775-30163W00000X
WI5890363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1033524749Medicaid
WI5890-33OtherSTATE LICENSE
CT200775-30OtherSTATE LICENSE