Provider Demographics
NPI:1649358169
Name:SORENSEN, MARY ELLEN I (APNP)
Entity type:Individual
Prefix:MS
First Name:MARY ELLEN
Middle Name:I
Last Name:SORENSEN
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:MARY ELLEN
Other - Middle Name:I
Other - Last Name:KOSKI
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:
Practice Address - Street 1:2000 E LAYTON AVE
Practice Address - Street 2:#100
Practice Address - City:ST FRANCIS
Practice Address - State:WI
Practice Address - Zip Code:53235
Practice Address - Country:US
Practice Address - Phone:414-744-6589
Practice Address - Fax:414-747-8848
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI920-033363L00000X
WI54783-030363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner