Provider Demographics
NPI:1659977510
Name:OLDENBURG, KIMBERLY SUE (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:OLDENBURG
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 1:2300 N STALLMAN RD
Mailing Address - Street 2:
Mailing Address - City:SUTTONS BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49682-9158
Mailing Address - Country:US
Mailing Address - Phone:231-534-7200
Mailing Address - Fax:
Practice Address - Street 1:2300 N STALLMAN RD
Practice Address - Street 2:
Practice Address - City:SUTTONS BAY
Practice Address - State:MI
Practice Address - Zip Code:49682-9158
Practice Address - Country:US
Practice Address - Phone:231-534-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-07
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704283424163W00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse