Provider Demographics
NPI:1780202663
Name:BUNTROCK, JULIE (APNP)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:
Last Name:BUNTROCK
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 S MOORLAND RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-7494
Mailing Address - Country:US
Mailing Address - Phone:262-789-6020
Mailing Address - Fax:262-789-6025
Practice Address - Street 1:4855 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7494
Practice Address - Country:US
Practice Address - Phone:262-789-6020
Practice Address - Fax:262-789-6025
Is Sole Proprietor?:No
Enumeration Date:2020-07-08
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9992363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780202663Medicaid