Provider Demographics
NPI:1154067239
Name:BOERST, KATIE (FNP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:BOERST
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-6006
Mailing Address - Country:US
Mailing Address - Phone:920-764-0132
Mailing Address - Fax:
Practice Address - Street 1:W5282 AMY AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-7233
Practice Address - Country:US
Practice Address - Phone:920-358-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-11
Last Update Date:2022-08-02
Deactivation Date:2022-07-08
Deactivation Code:
Reactivation Date:2022-08-02
Provider Licenses
StateLicense IDTaxonomies
WI220741-30163W00000X
WI13024-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse