Provider Demographics
NPI:1336551175
Name:WIETBROCK, MARY ANN (RN MSN CNS)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:WIETBROCK
Suffix:
Gender:F
Credentials:RN MSN CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4108 W 400 S
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163-9612
Mailing Address - Country:US
Mailing Address - Phone:317-410-9140
Mailing Address - Fax:
Practice Address - Street 1:4108 W 400 S
Practice Address - Street 2:
Practice Address - City:NEW PALESTINE
Practice Address - State:IN
Practice Address - Zip Code:46163-9612
Practice Address - Country:US
Practice Address - Phone:317-410-9140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28088637A364SC1501X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC1501XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCommunity Health/Public Health