Provider Demographics
NPI:1902095409
Name:CROWDER, MARY A (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:A
Last Name:CROWDER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2379 N 63RD ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-1543
Mailing Address - Country:US
Mailing Address - Phone:414-771-6507
Mailing Address - Fax:414-771-1181
Practice Address - Street 1:2379 N 63RD ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-1543
Practice Address - Country:US
Practice Address - Phone:414-771-6507
Practice Address - Fax:414-771-1181
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-20
Last Update Date:2007-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI44018000Medicaid