Healthcare Provider Details

I. General information

NPI: 1528234085
Provider Name (Legal Business Name): KIMULA A WILSON RN, FNP-BC, APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 08/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5300 W VILLARD AVE
MILWAUKEE WI
53218-4345
US

IV. Provider business mailing address

5300 W VILLARD AVE
MILWAUKEE WI
53218-4345
US

V. Phone/Fax

Practice location:
  • Phone: 414-438-6666
  • Fax: 414-438-6667
Mailing address:
  • Phone: 414-438-6666
  • Fax: 414-438-6667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3471-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number151449-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: