Provider Demographics
NPI:1407986698
Name:ORTMAN BROCKMUELLER, CHARISSE
Entity Type:Individual
Prefix:
First Name:CHARISSE
Middle Name:
Last Name:ORTMAN BROCKMUELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARISSE
Other - Middle Name:
Other - Last Name:ORTMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:
Practice Address - Street 1:1600 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1521
Practice Address - Country:US
Practice Address - Phone:605-312-1000
Practice Address - Fax:605-312-1001
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD000492363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal