Provider Demographics
NPI:1871517565
Name:LEVEILLE, MARY THERESE (APNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:THERESE
Last Name:LEVEILLE
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:THERESE
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:WI
Mailing Address - Zip Code:54165
Mailing Address - Country:US
Mailing Address - Phone:920-833-5100
Mailing Address - Fax:920-833-5130
Practice Address - Street 1:1100 ORCHARD ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:WI
Practice Address - Zip Code:54165
Practice Address - Country:US
Practice Address - Phone:920-833-5100
Practice Address - Fax:920-833-5130
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI69002163W00000X
WI1456363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43909800Medicaid
07125-0068Medicare ID - Type Unspecified
WI43909800Medicaid