Healthcare Provider Details

I. General information

NPI: 1255675799
Provider Name (Legal Business Name): KATHLEEN JEANEEN SUMMERS DNP, APNP, AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date: 04/15/2021
Reactivation Date: 06/25/2021

III. Provider practice location address

342 N WATER ST STE 600
MILWAUKEE WI
53202-5715
US

IV. Provider business mailing address

270 MAIN ST N STE 300
STILLWATER MN
55082-6788
US

V. Phone/Fax

Practice location:
  • Phone: 651-342-1039
  • Fax: 651-342-1428
Mailing address:
  • Phone: 651-342-1039
  • Fax: 651-342-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number10887-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number718-19
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number10887-33
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number10887-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: