Healthcare Provider Details

I. General information

NPI: 1174929285
Provider Name (Legal Business Name): KIM WOLLER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 QUAW AVE
EDGAR WI
54426-9316
US

IV. Provider business mailing address

319 QUAW AVE
EDGAR WI
54426-9316
US

V. Phone/Fax

Practice location:
  • Phone: 715-352-3593
  • Fax:
Mailing address:
  • Phone: 715-352-3593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number318084
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number221487
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: