Provider Demographics
NPI:1710252408
Name:WITCZAK, TARA LYN (APN-BC)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:LYN
Last Name:WITCZAK
Suffix:
Gender:F
Credentials:APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 N RIVERCENTER DR
Mailing Address - Street 2:SUITE #206
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3981
Mailing Address - Country:US
Mailing Address - Phone:414-272-5623
Mailing Address - Fax:414-272-5617
Practice Address - Street 1:1555 N RIVERCENTER DR
Practice Address - Street 2:SUITE #206
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3981
Practice Address - Country:US
Practice Address - Phone:414-272-5623
Practice Address - Fax:414-272-5617
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4766-33363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health