Healthcare Provider Details

I. General information

NPI: 1518444694
Provider Name (Legal Business Name): TINA C BROSSOW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2018
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N16012 CTY RD T
WITHEE WI
54498-8353
US

IV. Provider business mailing address

PO BOX 74008272
CHICAGO IL
60674-8272
US

V. Phone/Fax

Practice location:
  • Phone: 872-231-3162
  • Fax:
Mailing address:
  • Phone: 872-231-3162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number8487-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: