Provider Demographics
NPI:1609107481
Name:BURKE, BRENDA JEAN
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JEAN
Last Name:BURKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:JEAN
Other - Last Name:BERTELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 HIGHLAND AVE
Mailing Address - Street 2:F4/120, MC 1510
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53792-0001
Mailing Address - Country:US
Mailing Address - Phone:608-263-8246
Mailing Address - Fax:608-262-1636
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:F4/120, MC 1510
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-263-8246
Practice Address - Fax:608-262-1636
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-19
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI864020133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1630-29OtherCERTIFIED DIETITIAN