Provider Demographics
NPI:1902807639
Name:BARKER, MARY ANNE (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:BARKER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 THEDA CLARK MEDICAL PLZ
Mailing Address - Street 2:SUITE 240
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2721
Mailing Address - Country:US
Mailing Address - Phone:920-725-2070
Mailing Address - Fax:920-725-4549
Practice Address - Street 1:200 THEDA CLARK MEDICAL PLZ
Practice Address - Street 2:SUITE 240
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2721
Practice Address - Country:US
Practice Address - Phone:920-725-2070
Practice Address - Fax:920-725-4549
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI217-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43819800Medicaid
P40009Medicare UPIN