Healthcare Provider Details

I. General information

NPI: 1043983059
Provider Name (Legal Business Name): BREANNA M VRETENAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4523 N 107TH ST
WAUWATOSA WI
53225-4526
US

IV. Provider business mailing address

12430 W EUCLID AVE APT 3
NEW BERLIN WI
53151-4662
US

V. Phone/Fax

Practice location:
  • Phone: 920-342-1675
  • Fax:
Mailing address:
  • Phone: 920-342-1675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13256-146
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2676-19
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: