Provider Demographics
NPI:1366603581
Name:WOLF, KIM MARIE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:MARIE
Last Name:WOLF
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13800 W MARIA DR
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-6889
Mailing Address - Country:US
Mailing Address - Phone:414-630-7156
Mailing Address - Fax:
Practice Address - Street 1:13800 W MARIA DR
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-6889
Practice Address - Country:US
Practice Address - Phone:414-529-4378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI966-033363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1366603581Medicaid
WI1366603581Medicaid
WI650030041Medicare PIN
WI738440088Medicare PIN