Provider Demographics
NPI:1669577482
Name:MUTH, MARY ALICE (APNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:MUTH
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 1:13750 W NATIONAL AVE
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-4588
Mailing Address - Country:US
Mailing Address - Phone:262-789-1699
Mailing Address - Fax:
Practice Address - Street 1:13750 W NATIONAL AVE
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES INC.
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4588
Practice Address - Country:US
Practice Address - Phone:262-789-1699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2862-033363L00000X
WI126341-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI68375Medicare PIN
WI68015-0110Medicare PIN
WI02120-0309Medicare PIN