Provider Demographics
NPI:1518441898
Name:USTRUCK, MARIE THERESE (FNP)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:THERESE
Last Name:USTRUCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:THERESE
Other - Last Name:RESCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8706 SADLER DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-1506
Mailing Address - Country:US
Mailing Address - Phone:262-939-1883
Mailing Address - Fax:
Practice Address - Street 1:16650 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5920
Practice Address - Country:US
Practice Address - Phone:414-777-3754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8348-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner