Provider Demographics
NPI:1891500906
Name:BROCKWAY, KATHERINE MARIE (NP)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:MARIE
Last Name:BROCKWAY
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1598 GHOST RIDER WAY
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-5722
Mailing Address - Country:US
Mailing Address - Phone:262-237-1345
Mailing Address - Fax:
Practice Address - Street 1:1185 CORPORATE CENTER DR
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4887
Practice Address - Country:US
Practice Address - Phone:262-928-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-07
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI221523-30163W00000X
WI16470-33363L00000X
WI16470363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner