Provider Demographics
NPI:1417334475
Name:THIRY, KIMBERLY G (F-NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:G
Last Name:THIRY
Suffix:
Gender:F
Credentials:F-NP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:G
Other - Last Name:GRUSCZYNSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
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 1:1118 S NEENAH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6335-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400213059Medicare Oscar/Certification
WIK400231397Medicare Oscar/Certification
WIK400261167Medicare Oscar/Certification
WIK400227401Medicare Oscar/Certification