Healthcare Provider Details

I. General information

NPI: 1932478500
Provider Name (Legal Business Name): KATHLEEN M. BERNDSEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/27/2011
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W6800 37TH ST
NEW LISBON WI
53950-9149
US

IV. Provider business mailing address

W6800 37TH ST
NEW LISBON WI
53950-9149
US

V. Phone/Fax

Practice location:
  • Phone: 608-562-5685
  • Fax:
Mailing address:
  • Phone: 608-562-5685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number100174-30
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number100174-30
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number100174-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: