Provider Demographics
NPI:1508812918
Name:YELLICK, MARY K (APNP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:K
Last Name:YELLICK
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:285 FOREST GROVE DR
Mailing Address - Street 2:STE 124
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3716
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:285 FOREST GROVE DR
Practice Address - Street 2:STE 124
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3716
Practice Address - Country:US
Practice Address - Phone:262-329-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1417363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1508812918Medicaid
WI36009400Medicaid
WI1508812918Medicaid
WI36009400Medicaid
WIK400118495Medicare PIN
Q71112Medicare UPIN