Provider Demographics
NPI:1295056828
Name:SEIDL, MARY R C (CPNP-AC, RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R C
Last Name:SEIDL
Suffix:
Gender:F
Credentials:CPNP-AC, RN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:R
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP-AC, RN
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-3360
Mailing Address - Fax:414-266-3563
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-3360
Practice Address - Fax:414-266-3563
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 234011-1163W00000X
MNCNP 4719363LP0222X
WI157162-30163W00000X
WI9275363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1295056828Medicaid