Healthcare Provider Details

I. General information

NPI: 1417396631
Provider Name (Legal Business Name): KIMBERLY NESSETH R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11101 W LINCOLN AVE
MILWAUKEE WI
53227-1133
US

IV. Provider business mailing address

11101 W LINCOLN AVE
MILWAUKEE WI
53227-1133
US

V. Phone/Fax

Practice location:
  • Phone: 414-203-4503
  • Fax: 414-328-3737
Mailing address:
  • Phone: 414-203-4503
  • Fax: 414-328-3737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number189837-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: