Provider Demographics
NPI:1225080955
Name:WILLISON, KIM MARIE (APNP)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MARIE
Last Name:WILLISON
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 1:2105 E ENTERPRISE AVE
Mailing Address - Street 2:STE 111
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913
Mailing Address - Country:US
Mailing Address - Phone:920-731-6611
Mailing Address - Fax:920-731-6732
Practice Address - Street 1:2105 E ENTERPRISE AVE
Practice Address - Street 2:STE 111
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913
Practice Address - Country:US
Practice Address - Phone:920-731-6611
Practice Address - Fax:920-731-6732
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2608363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41265800Medicaid
WI41265800Medicaid