Provider Demographics
NPI:1578795407
Name:HEIMMERMANN, MARY K (APNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:HEIMMERMANN
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:HEIMMERMANN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APNP
Mailing Address - Street 1:411 LINCOLN ST
Mailing Address - Street 2:NETWORK HOUSE CALLS
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2753
Mailing Address - Country:US
Mailing Address - Phone:920-886-0818
Mailing Address - Fax:920-427-1310
Practice Address - Street 1:411 LINCOLN ST
Practice Address - Street 2:NETWORK HOUSE CALLS
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2753
Practice Address - Country:US
Practice Address - Phone:920-886-0818
Practice Address - Fax:920-427-1310
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3841-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100005319Medicaid
WI100005319Medicaid
WI402200001Medicare PIN