Provider Demographics
NPI:1407533672
Name:BROEREN, MACKENZIE (APNP, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:BROEREN
Suffix:
Gender:
Credentials:APNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5337 W GRANDE MARKET DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8442
Mailing Address - Country:US
Mailing Address - Phone:920-731-7445
Mailing Address - Fax:920-404-2351
Practice Address - Street 1:5471 W WATERFORD LN
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8510
Practice Address - Country:US
Practice Address - Phone:920-731-7445
Practice Address - Fax:920-882-0437
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI229878-30163W00000X
WI14115-33363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100243971Medicaid
WI100279786Medicaid