=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043983059
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BREANNA M VRETENAR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2021
-----------------------------------------------------
Last Update Date | 09/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4523 N 107TH ST
-----------------------------------------------------
City | WAUWATOSA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53225-4526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-342-1675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12430 W EUCLID AVE APT 3
-----------------------------------------------------
City | NEW BERLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53151-4662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-342-1675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 13256-146
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2676-19
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------