Healthcare Provider Details

I. General information

NPI: 1497365720
Provider Name (Legal Business Name): SAMANTHA ANN BROGHAMMER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2020
Last Update Date: 08/02/2020
Certification Date: 08/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 W SCHROEDER DR
BROWN DEER WI
53223-6458
US

IV. Provider business mailing address

344A N 68TH ST
WAUWATOSA WI
53213-3931
US

V. Phone/Fax

Practice location:
  • Phone: 414-865-2500
  • Fax:
Mailing address:
  • Phone: 920-946-2855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86095627
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: