Healthcare Provider Details

I. General information

NPI: 1871018564
Provider Name (Legal Business Name): CORY KATSMA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7395 FREDERICK PL
WEST BEND WI
53090-8643
US

IV. Provider business mailing address

7395 FREDERICK PL
WEST BEND WI
53090-8643
US

V. Phone/Fax

Practice location:
  • Phone: 262-339-8093
  • Fax:
Mailing address:
  • Phone: 262-339-8093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number321915-31
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number243446-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: