Provider Demographics
NPI:1689327314
Name:GOVAN, MARICETA ANN
Entity type:Individual
Prefix:
First Name:MARICETA
Middle Name:ANN
Last Name:GOVAN
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 1:333 WEST BROWN DEER RD
Mailing Address - Street 2:SUITEG-507
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217
Mailing Address - Country:US
Mailing Address - Phone:414-210-9959
Mailing Address - Fax:
Practice Address - Street 1:333 W BROWN DEER RD # 507
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-2372
Practice Address - Country:US
Practice Address - Phone:414-210-9959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver