Provider Demographics
NPI:1669936092
Name:BREITLOW, CHERYL ANN (BSN, RN)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:ANN
Last Name:BREITLOW
Suffix:
Gender:F
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W264N4974 BAYBERRY DR
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-1114
Mailing Address - Country:US
Mailing Address - Phone:262-224-4407
Mailing Address - Fax:
Practice Address - Street 1:W264N4974 BAYBERRY DR
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-1114
Practice Address - Country:US
Practice Address - Phone:262-224-4407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI82550163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIAHT462302AHCOtherANTHEM BLUECROSS BLUESHIELD