Healthcare Provider Details

I. General information

NPI: 1174824312
Provider Name (Legal Business Name): KIMBERLY SWEET RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 SAINT ANDREW ST STE 100
LA CROSSE WI
54603-2378
US

IV. Provider business mailing address

W3696 FENNIGKOH RD
WEST SALEM WI
54669-9550
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-6266
  • Fax:
Mailing address:
  • Phone: 608-786-3310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number136044-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: