Provider Demographics
NPI:1255662078
Name:WALTERS-CROSS, KIM MARIE (NURSE)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:WALTERS-CROSS
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W6092 WOODS FLOWAGE RD
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:WI
Mailing Address - Zip Code:54418-9591
Mailing Address - Country:US
Mailing Address - Phone:715-623-3506
Mailing Address - Fax:715-627-2738
Practice Address - Street 1:2215 PROGRESS BLVD
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2480
Practice Address - Country:US
Practice Address - Phone:715-623-3797
Practice Address - Fax:715-627-2738
Is Sole Proprietor?:No
Enumeration Date:2010-01-18
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI307904-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse