Provider Demographics
NPI:1477584266
Name:BRATVOLD, LISA M (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BRATVOLD
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 1:11040 N STATE RD 77
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-3606
Mailing Address - Country:US
Mailing Address - Phone:715-934-4910
Mailing Address - Fax:715-934-4620
Practice Address - Street 1:11040 N STATE RD 77
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-3606
Practice Address - Country:US
Practice Address - Phone:715-934-4910
Practice Address - Fax:715-934-4620
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2823363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIAPPRMedicaid