Provider Demographics
NPI:1114995560
Name:MUTH, BRENDA (NP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:MUTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13402 W TRAVIS TRCE
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53536-8115
Mailing Address - Country:US
Mailing Address - Phone:608-295-5550
Mailing Address - Fax:
Practice Address - Street 1:13402 W TRAVIS TRCE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-8115
Practice Address - Country:US
Practice Address - Phone:608-295-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2224363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner