Provider Demographics
NPI:1114774353
Name:WALLIN, KYMM ANN
Entity type:Individual
Prefix:
First Name:KYMM ANN
Middle Name:
Last Name:WALLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2402 WINNEBAGO ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-5341
Practice Address - Country:US
Practice Address - Phone:608-242-6840
Practice Address - Fax:608-245-6117
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI150068367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife