Healthcare Provider Details

I. General information

NPI: 1497632103
Provider Name (Legal Business Name): KIMBERLY KATE MIZELLE APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N2950 STATE ROAD 67
LAKE GENEVA WI
53147-2655
US

IV. Provider business mailing address

225 GRACE ST
WALWORTH WI
53184-9636
US

V. Phone/Fax

Practice location:
  • Phone: 262-245-0535
  • Fax: 262-245-4627
Mailing address:
  • Phone: 262-745-9353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number179925-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: