Healthcare Provider Details

I. General information

NPI: 1851630834
Provider Name (Legal Business Name): SUZETTE M BORNEMANN APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUZETTE M KITTELSON

II. Dates (important events)

Enumeration Date: 02/11/2013
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 S HWY 141
CRIVITZ WI
54114-1677
US

IV. Provider business mailing address

PO BOX 1866
GREEN BAY WI
54305-1866
US

V. Phone/Fax

Practice location:
  • Phone: 715-854-7477
  • Fax: 715-854-7785
Mailing address:
  • Phone: 920-445-7210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number5219-33
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5219-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: