Provider Demographics
NPI:1871122556
Name:KOFIGAH, MARY (10020 - 33 NP)
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:
Last Name:KOFIGAH
Suffix:
Gender:
Credentials:10020 - 33 NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:946 N VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3216
Mailing Address - Country:US
Mailing Address - Phone:414-671-9355
Mailing Address - Fax:888-376-4067
Practice Address - Street 1:946 N VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-3216
Practice Address - Country:US
Practice Address - Phone:414-671-9355
Practice Address - Fax:888-376-4067
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-05
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002033363LF0000X
WI2024001821363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily