Provider Demographics
NPI:1336551175
Name:WIETBROCK, MARY ANN (RN MSN ACNS-BC)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:WIETBROCK
Suffix:
Gender:F
Credentials:RN MSN ACNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4108 W 400 S
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163-9612
Mailing Address - Country:US
Mailing Address - Phone:317-410-9140
Mailing Address - Fax:
Practice Address - Street 1:102 GRANBY DR
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:IN
Practice Address - Zip Code:46229-4203
Practice Address - Country:US
Practice Address - Phone:317-410-9140
Practice Address - Fax:317-861-1556
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-28
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN28088637A364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty