Healthcare Provider Details

I. General information

NPI: 1669192977
Provider Name (Legal Business Name): ANDREA ELIZABETH HRUZEK-GRABER APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 MIDWAY RD
MENASHA WI
54952-7002
US

IV. Provider business mailing address

540 WINDMILL DR
KIMBERLY WI
54136-2134
US

V. Phone/Fax

Practice location:
  • Phone: 920-832-8500
  • Fax:
Mailing address:
  • Phone: 920-470-0889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13096-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: