Provider Demographics
NPI:1255675799
Name:SUMMERS, KATHLEEN JEANEEN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JEANEEN
Last Name:SUMMERS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9019 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-6601
Mailing Address - Country:US
Mailing Address - Phone:262-914-1063
Mailing Address - Fax:
Practice Address - Street 1:9244 29TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-6602
Practice Address - Country:US
Practice Address - Phone:262-694-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2021-06-30
Deactivation Date:2021-04-15
Deactivation Code:
Reactivation Date:2021-06-25
Provider Licenses
StateLicense IDTaxonomies
WI718-19225200000X
WI10887-33363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant