Healthcare Provider Details

I. General information

NPI: 1407220239
Provider Name (Legal Business Name): BREANA M VANDOORN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BREANA BOND

II. Dates (important events)

Enumeration Date: 11/17/2015
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 N WESTHAVEN DR
OSHKOSH WI
54904-7668
US

IV. Provider business mailing address

525 FOX FIRE DR
OSHKOSH WI
54904-6585
US

V. Phone/Fax

Practice location:
  • Phone: 920-303-8700
  • Fax:
Mailing address:
  • Phone: 920-410-3882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number157210-030
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number106908
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: