Provider Demographics
NPI:1568185114
Name:VANMERSBERGEN, BRENDA MARIE (AGPCNP)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:MARIE
Last Name:VANMERSBERGEN
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 N GRANDVIEW BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-6906
Mailing Address - Country:US
Mailing Address - Phone:262-875-5070
Mailing Address - Fax:
Practice Address - Street 1:230 N PRAIRIE DR
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-8617
Practice Address - Country:US
Practice Address - Phone:262-468-8883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1314833363LA2200X
WI13148363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1314833OtherSTATE LICENSE