Provider Demographics
NPI:1346896594
Name:CLEMENTI, MARY E (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:CLEMENTI
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:GOODALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2930 N HUMBOLDT BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2632
Mailing Address - Country:US
Mailing Address - Phone:847-276-8820
Mailing Address - Fax:
Practice Address - Street 1:945 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1305
Practice Address - Country:US
Practice Address - Phone:414-219-7733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIF04190076363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily