Provider Demographics
NPI:1598996258
Name:WILLETT, MARJORIE ANN (APNP)
Entity Type:Individual
Prefix:MRS
First Name:MARJORIE
Middle Name:ANN
Last Name:WILLETT
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:MISS
Other - First Name:MARJORIE
Other - Middle Name:ANN
Other - Last Name:POLITOSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:262-741-2380
Mailing Address - Fax:
Practice Address - Street 1:W3985 COUNTY ROAD NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4337
Practice Address - Country:US
Practice Address - Phone:262-741-2380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3813-33363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100005788Medicaid
WI685900027Medicare PIN
WI013630027Medicare PIN