Healthcare Provider Details

I. General information

NPI: 1235180076
Provider Name (Legal Business Name): TERRY A KOLLENBROICH CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 FOREST LN
WATERFORD WI
53185-4585
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 262-514-3700
  • Fax: 262-514-3867
Mailing address:
  • Phone: 800-326-6250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2373
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: