=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356040612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHY ANN GATES FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2023
-----------------------------------------------------
Last Update Date | 07/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 370 3RD AVENUE
-----------------------------------------------------
City | CLEAR LAKE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54005-9658
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-554-4224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 133
-----------------------------------------------------
City | CLEAR LAKE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54005-0133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 715-554-4224
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 13578-33
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------