Provider Demographics
NPI:1508571720
Name:WOLTER, MARY ANN (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:WOLTER
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1832 E BENNETT AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-2961
Mailing Address - Country:US
Mailing Address - Phone:224-213-2222
Mailing Address - Fax:
Practice Address - Street 1:7950 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:FOX POINT
Practice Address - State:WI
Practice Address - Zip Code:53217-3131
Practice Address - Country:US
Practice Address - Phone:414-253-1194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13429-33363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics