Provider Demographics
NPI:1093701831
Name:RESZCZYNSKI, MARY (APNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:RESZCZYNSKI
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 1:632 FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:KIEL
Mailing Address - State:WI
Mailing Address - Zip Code:53042-1321
Mailing Address - Country:US
Mailing Address - Phone:920-894-3222
Mailing Address - Fax:
Practice Address - Street 1:632 FREMONT ST
Practice Address - Street 2:
Practice Address - City:KIEL
Practice Address - State:WI
Practice Address - Zip Code:53042-1321
Practice Address - Country:US
Practice Address - Phone:920-894-3222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI102705-030363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43910200Medicaid
WI43910200Medicaid