Provider Demographics
NPI:1760595110
Name:TAGGETT, MARY E (APNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:TAGGETT
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1185 CORPORATE CENTER DR
Mailing Address - Street 2:STE 175
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4887
Mailing Address - Country:US
Mailing Address - Phone:262-928-8400
Mailing Address - Fax:
Practice Address - Street 1:1185 CORPORATE CENTER DR
Practice Address - Street 2:STE 175
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4887
Practice Address - Country:US
Practice Address - Phone:262-928-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI105021363LA2100X
WI2200363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
000068375Medicare PIN
WI13195-0005Medicare ID - Type Unspecified
WIP80735Medicare UPIN
WI16220-0005Medicare ID - Type Unspecified