Provider Demographics
NPI:1508171174
Name:NIEVES, MARYELLEN M (APNP)
Entity Type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:M
Last Name:NIEVES
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 1:4061 OLD PESHTIGO RD
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-3887
Mailing Address - Country:US
Mailing Address - Phone:715-732-8000
Mailing Address - Fax:
Practice Address - Street 1:4061 OLD PESHTIGO RD
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3887
Practice Address - Country:US
Practice Address - Phone:715-732-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-08
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2009007522363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40120-0237Medicare PIN