Healthcare Provider Details

I. General information

NPI: 1255747325
Provider Name (Legal Business Name): KATHRYN GRACE WARREN APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN GRACE LEITERMAN APNP

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2714 RIVERVIEW DR
GREEN BAY WI
54313-6715
US

IV. Provider business mailing address

PO BOX 22487
GREEN BAY WI
54305-2487
US

V. Phone/Fax

Practice location:
  • Phone: 920-430-4760
  • Fax: 920-430-4774
Mailing address:
  • Phone: 920-445-7210
  • Fax: 920-445-7289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5881-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number138209-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: