Provider Demographics
NPI:1316028616
Name:NUNCHUCK, MARY INEZ (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:INEZ
Last Name:NUNCHUCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1717 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53403-2405
Mailing Address - Country:US
Mailing Address - Phone:262-638-6744
Mailing Address - Fax:262-638-6540
Practice Address - Street 1:1717 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-2405
Practice Address - Country:US
Practice Address - Phone:262-638-6744
Practice Address - Fax:262-638-6540
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI3772600212084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry