Provider Demographics
NPI:1053708222
Name:KIRCHNER, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KIRCHNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2999 WEST SPENCER STREET
Mailing Address - Street 2:SUITE 2060
Mailing Address - City:GRAND CHUTE
Mailing Address - State:WI
Mailing Address - Zip Code:54914
Mailing Address - Country:US
Mailing Address - Phone:920-574-2272
Mailing Address - Fax:
Practice Address - Street 1:2999 W SPENCER ST
Practice Address - Street 2:SUITE 2060
Practice Address - City:GRAND CHUTE
Practice Address - State:WI
Practice Address - Zip Code:54914-4352
Practice Address - Country:US
Practice Address - Phone:920-574-2272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-24
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1053708222Medicaid