Provider Demographics
NPI:1346355542
Name:DUCZAK, KIM T (APNP)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:T
Last Name:DUCZAK
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:TRACY
Other - Last Name:NAUTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:262-514-3700
Mailing Address - Fax:262-514-3865
Practice Address - Street 1:818 FORREST LN
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185
Practice Address - Country:US
Practice Address - Phone:262-514-3700
Practice Address - Fax:262-514-3865
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1544-033363L00000X
WI80028-030363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4393500Medicaid
596275Medicare UPIN