Basic Information
Provider Information | |||||||||
NPI: | 1023125580 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MARCHETTA | ||||||||
FirstName: | ANN | ||||||||
MiddleName: | E | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 701 GROVE AVE | ||||||||
Address2: | PO BOX 314 | ||||||||
City: | WILD ROSE | ||||||||
State: | WI | ||||||||
PostalCode: | 549846901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9206225560 | ||||||||
FaxNumber: | 9206225598 | ||||||||
Practice Location | |||||||||
Address1: | 1533 S BROWNLEE BLVD STE 100 | ||||||||
Address2: |   | ||||||||
City: | CORPUS CHRISTI | ||||||||
State: | TX | ||||||||
PostalCode: | 784043131 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3618842242 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2006 | ||||||||
LastUpdateDate: | 10/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 943-033 | WI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363L00000X | 650349 | TX | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 363LF0000X | 05 | WI |   | MEDICAID |