1215139860 NPI number — MRS. NANCY RUTH MACZKA ADULT PMHNP

Table of content: MRS. NANCY RUTH MACZKA ADULT PMHNP (NPI 1215139860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215139860 NPI number — MRS. NANCY RUTH MACZKA ADULT PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACZKA
Provider First Name:
NANCY
Provider Middle Name:
RUTH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ADULT PMHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
REGIER
Provider Other First Name:
NANCY
Provider Other Middle Name:
RUTH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215139860
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1244 WISCONSIN AVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
RACINE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53403-1987
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-687-2219
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1244 WISCONSIN AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
RACINE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53403-1987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-687-2219
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X , with the licence number:  2081-033 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 36038300 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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