Healthcare Provider Details

I. General information

NPI: 1154014587
Provider Name (Legal Business Name): KAYLA HIMEBAUCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 W INNOVATION DR STE 400
MILWAUKEE WI
53226-4826
US

IV. Provider business mailing address

10200 W INNOVATION DR STE 400
MILWAUKEE WI
53226-4826
US

V. Phone/Fax

Practice location:
  • Phone: 414-944-2000
  • Fax:
Mailing address:
  • Phone: 414-944-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2023003353
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: