Provider Demographics
NPI:1467976357
Name:PHARO, KYM A (DNP, PMHNP-BC, FNP-B)
Entity Type:Individual
Prefix:
First Name:KYM
Middle Name:A
Last Name:PHARO
Suffix:
Gender:F
Credentials:DNP, PMHNP-BC, FNP-B
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 301
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0301
Mailing Address - Country:US
Mailing Address - Phone:608-742-5518
Mailing Address - Fax:608-742-4087
Practice Address - Street 1:2901 HUNTERS TRL
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-3403
Practice Address - Country:US
Practice Address - Phone:608-742-5518
Practice Address - Fax:608-742-4087
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI193271363LF0000X
WI7832-33363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1467976357Medicaid