Provider Demographics
NPI:1770574162
Name:GATIEN BRUX, DENISE R (NP)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:R
Last Name:GATIEN BRUX
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:
Practice Address - Street 1:723 PARK RIDGE LN
Practice Address - Street 2:
Practice Address - City:NORTH FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-1385
Practice Address - Country:US
Practice Address - Phone:920-926-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI103096363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI12658OtherDEAN
WI500000913OtherRAILROAD MEDICARE
WV1002654OtherTOUCHPOINT
WI39080723684OtherUNITY
WIWI01N8OtherJOHN DEERE
WI43833400Medicaid