Provider Demographics
NPI:1023455862
Name:MOON, MARYANN MCKENNA (RN CNS)
Entity type:Individual
Prefix:MRS
First Name:MARYANN
Middle Name:MCKENNA
Last Name:MOON
Suffix:
Gender:F
Credentials:RN CNS
Other - Prefix:MISS
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:MCKENNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-8700
Mailing Address - Fax:414-259-1522
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-8700
Practice Address - Fax:414-259-1522
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6944363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner