Provider Demographics
NPI:1790457638
Name:BROCKDORF, PAIGE (DNP, APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:BROCKDORF
Suffix:
Gender:
Credentials:DNP, APRN, FNP-BC
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:
Other - Last Name:DOMURAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5320 W MICHAELS DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8446
Mailing Address - Country:US
Mailing Address - Phone:920-882-8200
Mailing Address - Fax:
Practice Address - Street 1:5320 W MICHAELS DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8446
Practice Address - Country:US
Practice Address - Phone:920-882-8200
Practice Address - Fax:920-882-8210
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11108-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily