Provider Demographics
NPI:1689790461
Name:HEISE, MARYJO LEIGH (APNP)
Entity Type:Individual
Prefix:MRS
First Name:MARYJO
Middle Name:LEIGH
Last Name:HEISE
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:720 S VANBUREN ST
Practice Address - Street 2:SUITE201
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3534
Practice Address - Country:US
Practice Address - Phone:920-433-7488
Practice Address - Fax:920-433-7439
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI135351-030163W00000X
WI5010-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
F0812139OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS