Healthcare Provider Details

I. General information

NPI: 1942933148
Provider Name (Legal Business Name): BRENDA BIRD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6515 GRAND TETON PLZ
MADISON WI
53719-1048
US

IV. Provider business mailing address

6515 GRAND TETON PLZ
MADISON WI
53719-1048
US

V. Phone/Fax

Practice location:
  • Phone: 608-713-9898
  • Fax:
Mailing address:
  • Phone: 608-713-9898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7513-23
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number218791-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: