Provider Demographics
NPI:1184974826
Name:BRUCKNER, KATIE SUE (APNP)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:SUE
Last Name:BRUCKNER
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 PERSNICKETY PL
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-3544
Mailing Address - Country:US
Mailing Address - Phone:920-892-3468
Mailing Address - Fax:920-892-5385
Practice Address - Street 1:1 PERSNICKETY PL
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:WI
Practice Address - Zip Code:53073-3544
Practice Address - Country:US
Practice Address - Phone:920-892-3468
Practice Address - Fax:920-892-5385
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5007-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily