Provider Demographics
NPI:1407384241
Name:NIEMUTH, KENDRA (RN BSN)
Entity Type:Individual
Prefix:MRS
First Name:KENDRA
Middle Name:
Last Name:NIEMUTH
Suffix:
Gender:F
Credentials:RN BSN
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 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:958 FOOTE ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:WI
Practice Address - Zip Code:54165-1044
Practice Address - Country:US
Practice Address - Phone:920-833-9896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI190067-30163W00000X
WI7736-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI7736-33OtherAPNP LICENSE