Provider Demographics
NPI:1598023939
Name:BOLLMEIER, KIMBERLY ANN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:BOLLMEIER
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9146
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:8501 75TH ST STE J
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7602
Practice Address - Country:US
Practice Address - Phone:262-697-8030
Practice Address - Fax:262-697-6157
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085.004647363A00000X
WI3083-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL906720005Medicare PIN