Provider Demographics
NPI:1093346629
Name:ROESELER, MARY ANN (LAC)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:ROESELER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4027 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-4313
Mailing Address - Country:US
Mailing Address - Phone:414-628-2336
Mailing Address - Fax:
Practice Address - Street 1:4027 S 2ND ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53207-4313
Practice Address - Country:US
Practice Address - Phone:414-628-2336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-02
Last Update Date:2020-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI996-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist