Basic Information
Provider Information | |||||||||
NPI: | 1669572566 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MATTICE | ||||||||
FirstName: | MARGARET | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSN, APNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 888 THACKERAY TRL 103 | ||||||||
Address2: |   | ||||||||
City: | OCONOMOWOC | ||||||||
State: | WI | ||||||||
PostalCode: | 530664342 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2623543744 | ||||||||
FaxNumber: | 2623543748 | ||||||||
Practice Location | |||||||||
Address1: | 1145 W MAIN AVE | ||||||||
Address2: | STE. 205 | ||||||||
City: | DE PERE | ||||||||
State: | WI | ||||||||
PostalCode: | 541151698 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9203366455 | ||||||||
FaxNumber: | 9203366646 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 12/16/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 2749-33 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
ID | Type | State | Issuer | Description | 41268900 | 05 | WI |   | MEDICAID |