Provider Demographics
NPI:1891074407
Name:BRZAKALA, CHRISTINE ANN (APNP)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ANN
Last Name:BRZAKALA
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 1:1475 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-2074
Mailing Address - Country:US
Mailing Address - Phone:262-268-5100
Mailing Address - Fax:
Practice Address - Street 1:1475 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2074
Practice Address - Country:US
Practice Address - Phone:262-268-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008966A363LF0000X
WI4506-033363L00000X
WI450633363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100017022Medicaid
IN300025766Medicaid