Healthcare Provider Details

I. General information

NPI: 1487225405
Provider Name (Legal Business Name): BRENDA LEE FONDER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BRENDA LEE KURTH RN

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6410 MILITARY RD
LENA WI
54139-9188
US

IV. Provider business mailing address

6410 MILITARY RD
LENA WI
54139-9188
US

V. Phone/Fax

Practice location:
  • Phone: 920-604-3023
  • Fax:
Mailing address:
  • Phone: 920-604-3023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number116995-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: