Provider Demographics
NPI:1124673611
Name:KUMMROW, KIM MARIE (SFA-C)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:KUMMROW
Suffix:
Gender:F
Credentials:SFA-C
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:MARIE
Other - Last Name:LEICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SFA-C
Mailing Address - Street 1:W340N6697 TIMBERLINE RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-5151
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9000 W WISCONSIN AVE STE 360
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-337-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant