Provider Demographics
NPI:1407220239
Name:VANDOORN, BREANA M (CRNA)
Entity Type:Individual
Prefix:
First Name:BREANA
Middle Name:M
Last Name:VANDOORN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:BREANA
Other - Middle Name:
Other - Last Name:BOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:525 FOX FIRE DR
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-6585
Mailing Address - Country:US
Mailing Address - Phone:920-410-3882
Mailing Address - Fax:
Practice Address - Street 1:855 N WESTHAVEN DR
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7668
Practice Address - Country:US
Practice Address - Phone:920-303-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI157210-030163WC0200X
WI106908367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100052597Medicaid