Provider Demographics
NPI:1073954491
Name:ROEHRBORN DORAU, BRENDA JEAN (LPN)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JEAN
Last Name:ROEHRBORN DORAU
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5502 STATE ROAD 28
Mailing Address - Street 2:
Mailing Address - City:WALDO
Mailing Address - State:WI
Mailing Address - Zip Code:53093-1208
Mailing Address - Country:US
Mailing Address - Phone:920-207-8918
Mailing Address - Fax:
Practice Address - Street 1:W5502 STATE ROAD 28
Practice Address - Street 2:
Practice Address - City:WALDO
Practice Address - State:WI
Practice Address - Zip Code:53093-1208
Practice Address - Country:US
Practice Address - Phone:920-207-8918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-14
Last Update Date:2013-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI314406-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse