Provider Demographics
NPI:1184403305
Name:MARA, MICHELLE ROSE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ROSE
Last Name:MARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ROSE
Other - Last Name:BEIERMEISTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11400 W LAKE PARK DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-3035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11400 W LAKE PARK DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-3035
Practice Address - Country:US
Practice Address - Phone:414-365-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14430-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily