Provider Demographics
NPI:1114481942
Name:KIDD, MARY R (APNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:KIDD
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:610 S LINCOLN RD
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1215
Practice Address - Country:US
Practice Address - Phone:906-786-6488
Practice Address - Fax:906-786-6409
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704305878163W00000X, 363LF0000X
WI246069-30163W00000X
WI9045-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
F09181074OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS