Provider Demographics
NPI:1386049492
Name:NIEZGODA, KATHLEEN MARY (RN, MSN, CPNP, PMHS)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:NIEZGODA
Suffix:
Gender:F
Credentials:RN, MSN, CPNP, PMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W LAYTON AVE
Mailing Address - Street 2:SUITE 30
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-5420
Mailing Address - Country:US
Mailing Address - Phone:414-269-5336
Mailing Address - Fax:414-269-5437
Practice Address - Street 1:2500 W LAYTON AVE
Practice Address - Street 2:SUITE 30
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-5420
Practice Address - Country:US
Practice Address - Phone:414-269-5336
Practice Address - Fax:414-269-5437
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-31
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5744-33363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics