Provider Demographics
NPI:1588837983
Name:KRIENKE, MARY (PT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KRIENKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3336 NAGAWICKA AVE
Mailing Address - Street 2:
Mailing Address - City:DELAFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53018-1021
Mailing Address - Country:US
Mailing Address - Phone:262-646-4633
Mailing Address - Fax:
Practice Address - Street 1:3336 NAGAWICKA AVE
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-1021
Practice Address - Country:US
Practice Address - Phone:262-646-4633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1763-024172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40025200Medicaid