Healthcare Provider Details

I. General information

NPI: 1124565882
Provider Name (Legal Business Name): BRENDA STALLBAUM APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 06/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 REED AVE
MANITOWOC WI
54220-2020
US

IV. Provider business mailing address

PO BOX 2290
MANITOWOC WI
54221-2290
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-8600
  • Fax:
Mailing address:
  • Phone: 920-320-2591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number7373-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: