Healthcare Provider Details

I. General information

NPI: 1023254018
Provider Name (Legal Business Name): PAMELA SUE BRUCKER LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2008
Last Update Date: 12/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W7755 CTY RD V
CASCADE WI
53011-1234
US

IV. Provider business mailing address

W 7755 CTY. RD. V
CASCADE WI
53011-1234
US

V. Phone/Fax

Practice location:
  • Phone: 920-528-8198
  • Fax: 920-528-7056
Mailing address:
  • Phone: 920-528-8198
  • Fax: 920-528-7056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number14165-031
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: