Provider Demographics
NPI:1689696007
Name:BURGOYNE, MARY JO (RN, MSN, APNP)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:
Last Name:BURGOYNE
Suffix:
Gender:F
Credentials:RN, MSN, APNP
Other - Prefix:
Other - First Name:MARY JO
Other - Middle Name:
Other - Last Name:SIMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1522 N PROSPECT AVE
Mailing Address - Street 2:SUITE 1006
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-6512
Mailing Address - Country:US
Mailing Address - Phone:414-916-4476
Mailing Address - Fax:414-805-0970
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:SUITE C-2130
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-9990
Practice Address - Fax:414-805-0970
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66695-030163W00000X
WI510-033364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40956800Medicaid
WI002184911Medicare PIN
WI40956800Medicaid