Provider Demographics
NPI:1184292666
Name:LUND, BROOKE MARIE (STUDENT)
Entity type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:MARIE
Last Name:LUND
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1936 PARKNOLL LN
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-1177
Mailing Address - Country:US
Mailing Address - Phone:262-323-2962
Mailing Address - Fax:
Practice Address - Street 1:1936 PARKNOLL LN
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-1177
Practice Address - Country:US
Practice Address - Phone:262-323-2962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WINONE207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE