Healthcare Provider Details

I. General information

NPI: 1992549984
Provider Name (Legal Business Name): MCKENZIE GAIL BREAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 65TH AVE
OSCEOLA WI
54020-4376
US

IV. Provider business mailing address

2600 65TH AVE
OSCEOLA WI
54020-4376
US

V. Phone/Fax

Practice location:
  • Phone: 715-294-2111
  • Fax: 715-294-2874
Mailing address:
  • Phone: 715-294-2111
  • Fax: 715-294-2874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: