Provider Demographics
NPI:1083923049
Name:BERNDT, KIMBERLY JEAN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEAN
Last Name:BERNDT
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1527 TROUT SPRING RD
Mailing Address - Street 2:
Mailing Address - City:ADELL
Mailing Address - State:WI
Mailing Address - Zip Code:53001-1329
Mailing Address - Country:US
Mailing Address - Phone:262-305-6935
Mailing Address - Fax:
Practice Address - Street 1:2810 CROSSROADS DR STE 4000
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53718-8014
Practice Address - Country:US
Practice Address - Phone:855-300-9893
Practice Address - Fax:855-300-9893
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI174079-030163WP0808X, 163W00000X
WI8912-33163WP0808X, 363LP0808X
WI174079-30363L00000X
MT172631363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100083956Medicaid
WI100083911Medicaid
WI100126024Medicaid