Healthcare Provider Details

I. General information

NPI: 1992990667
Provider Name (Legal Business Name): BRENDA M VELDBOOM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BUTLER ST
RANDOM LAKE WI
53075-1708
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 920-994-9094
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3202-033
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: