MEDICARE: KIMBERLY G THIRY F-NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	6335-33	WI

General Provider Information

NPI Number	:	1417334475
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY G THIRY F-NP

Provider Business Mailing Address
First Line	:	PO BOX 19070
Second Line	:
City	:	GREEN BAY
State	:	WI
Zip	:	54307-9070
Country	:	US
Telephone Number	:	920-496-4700
Fax Number	:

Provider Business Practice Location Address
First Line	:	1118 S NEENAH AVE
Second Line	:
City	:	STURGEON BAY
State	:	WI
Zip	:	54235
Country	:	US
Telephone Number	:	920-496-4700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/29/2015
Last Update Date	:	10/18/2022

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