Provider Demographics
NPI:1962884270
Name:ZILLMER, BRAD
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:ZILLMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W8446 STATE ROAD 67
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:WI
Mailing Address - Zip Code:53585-9790
Mailing Address - Country:US
Mailing Address - Phone:262-745-9532
Mailing Address - Fax:
Practice Address - Street 1:W8446 STATE ROAD 67
Practice Address - Street 2:
Practice Address - City:SHARON
Practice Address - State:WI
Practice Address - Zip Code:53585-9790
Practice Address - Country:US
Practice Address - Phone:262-745-9532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI319377164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse