Provider Demographics
NPI:1740940733
Name:VANDER BLOOMEN, MACKENZIE ROSE (MSN, FNP-C)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:ROSE
Last Name:VANDER BLOOMEN
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:ROSE
Other - Last Name:DOROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1326 SAND ACRES DR
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-9487
Mailing Address - Country:US
Mailing Address - Phone:920-264-4346
Mailing Address - Fax:
Practice Address - Street 1:1860 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2667
Practice Address - Country:US
Practice Address - Phone:920-272-1010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-18
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI230930-30163W00000X
WI11824-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty