Healthcare Provider Details

I. General information

NPI: 1356743892
Provider Name (Legal Business Name): CHRISTINE GLEN APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13950 W CAPITOL DR
BROOKFIELD WI
53005-2441
US

IV. Provider business mailing address

13950 W CAPITOL DR
BROOKFIELD WI
53005-2441
US

V. Phone/Fax

Practice location:
  • Phone: 414-302-5400
  • Fax: 414-302-5495
Mailing address:
  • Phone: 414-302-5400
  • Fax: 414-302-5495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number6014
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number6014
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: