Provider Demographics
NPI:1275680290
Name:VAN BUREN, KIMBERLEY G (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:G
Last Name:VAN BUREN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:262-514-3700
Mailing Address - Fax:
Practice Address - Street 1:818 FORREST DR
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-4577
Practice Address - Country:US
Practice Address - Phone:262-514-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2030363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43956900Medicaid