Provider Demographics
NPI:1053429233
Name:SCHWANEBECK, MARY K (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:SCHWANEBECK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 DEWEY ST
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-4715
Mailing Address - Country:US
Mailing Address - Phone:715-421-7442
Mailing Address - Fax:715-421-7408
Practice Address - Street 1:410 DEWEY ST
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-4715
Practice Address - Country:US
Practice Address - Phone:715-421-7442
Practice Address - Fax:715-421-7408
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI97986363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43835200Medicaid
WI057572200Medicare ID - Type Unspecified
S17168Medicare UPIN