Healthcare Provider Details

I. General information

NPI: 1881246692
Provider Name (Legal Business Name): GRACE CATHERINE MORTRUDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W NATIONAL AVE
MILWAUKEE WI
53295-0001
US

IV. Provider business mailing address

777 N VAN BUREN ST APT 1210
MILWAUKEE WI
53202-3860
US

V. Phone/Fax

Practice location:
  • Phone: 414-384-2000
  • Fax:
Mailing address:
  • Phone: 414-239-2125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835I0206X
TaxonomyInfectious Diseases Pharmacist
License Number5315153295
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: