Provider Demographics
NPI:1508528878
Name:PENOSKE, BROOKE (EP-C)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:PENOSKE
Suffix:
Gender:F
Credentials:EP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1030 E EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8912
Mailing Address - Country:US
Mailing Address - Phone:414-248-0352
Mailing Address - Fax:
Practice Address - Street 1:1030 E EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8912
Practice Address - Country:US
Practice Address - Phone:414-248-0352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI