Provider Demographics
NPI:1134479132
Name:FERENCEVICH, KIM (RN)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:FERENCEVICH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:SCHMIDT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:144B N BARTON RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSPORT
Mailing Address - State:WI
Mailing Address - Zip Code:53010-2710
Mailing Address - Country:US
Mailing Address - Phone:920-420-5802
Mailing Address - Fax:
Practice Address - Street 1:144B N BARTON RD
Practice Address - Street 2:
Practice Address - City:CAMPBELLSPORT
Practice Address - State:WI
Practice Address - Zip Code:53010-2710
Practice Address - Country:US
Practice Address - Phone:920-420-5802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131538-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse