Healthcare Provider Details

I. General information

NPI: 1740940733
Provider Name (Legal Business Name): MACKENZIE ROSE VANDER BLOOMEN MSN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MACKENZIE ROSE DOROW

II. Dates (important events)

Enumeration Date: 12/18/2021
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 SHAWANO AVE
GREEN BAY WI
54303-2667
US

IV. Provider business mailing address

1326 SAND ACRES DR
DE PERE WI
54115-9487
US

V. Phone/Fax

Practice location:
  • Phone: 920-272-1010
  • Fax:
Mailing address:
  • Phone: 920-264-4346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11824-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number230930-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: