Provider Demographics
NPI:1104183219
Name:BUWALDA, KATHLEEN MAE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MAE
Last Name:BUWALDA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W13546 MARSHVIEW RD
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-9733
Mailing Address - Country:US
Mailing Address - Phone:920-324-9948
Mailing Address - Fax:
Practice Address - Street 1:W13546 MARSHVIEW RD
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-9733
Practice Address - Country:US
Practice Address - Phone:920-324-9948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI303291-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse