Provider Demographics
NPI:1568185403
Name:COLLICOTT, MARIAH M (NP)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:M
Last Name:COLLICOTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 E COMMERCE BLVD
Mailing Address - Street 2:
Mailing Address - City:SLINGER
Mailing Address - State:WI
Mailing Address - Zip Code:53086-9326
Mailing Address - Country:US
Mailing Address - Phone:262-644-2900
Mailing Address - Fax:
Practice Address - Street 1:1061 E COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:SLINGER
Practice Address - State:WI
Practice Address - Zip Code:53086-9326
Practice Address - Country:US
Practice Address - Phone:262-644-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13169-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner