Provider Demographics
NPI:1245227248
Name:GRANGER, KIMBERLY L (RNC MSN FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:L
Last Name:GRANGER
Suffix:
Gender:F
Credentials:RNC MSN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3807 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405
Mailing Address - Country:US
Mailing Address - Phone:262-687-8282
Mailing Address - Fax:262-687-6737
Practice Address - Street 1:3807 SPRING ST
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1667
Practice Address - Country:US
Practice Address - Phone:262-687-8282
Practice Address - Fax:262-687-6737
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI106-033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43839000Medicaid