Healthcare Provider Details

I. General information

NPI: 1164077079
Provider Name (Legal Business Name): THERESE MARIE BROKMEIER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8149 NORTH LN
ARGONNE WI
54511-8934
US

IV. Provider business mailing address

8149 NORTH LN
ARGONNE WI
54511-8934
US

V. Phone/Fax

Practice location:
  • Phone: 715-360-3907
  • Fax:
Mailing address:
  • Phone: 715-360-3907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number178386-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: