Provider Demographics
NPI:1053505362
Name:BEATTY-ROLOFF, MARY M (APNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:BEATTY-ROLOFF
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:M
Other - Last Name:BEATTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:N2919 CTY HWY QQ
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981
Mailing Address - Country:US
Mailing Address - Phone:715-258-2108
Mailing Address - Fax:715-942-2199
Practice Address - Street 1:N2919 CTY HWY QQ
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981
Practice Address - Country:US
Practice Address - Phone:715-258-2108
Practice Address - Fax:715-942-2199
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3195363L00000X
WI3195-033363L00000X
WI107505-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3195OtherWI STATE LICENSE