Provider Demographics
NPI:1710172614
Name:MITTELSTADT, KIM A (APNP)
Entity Type:Individual
Prefix:MISS
First Name:KIM
Middle Name:A
Last Name:MITTELSTADT
Suffix:
Gender:F
Credentials:APNP
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Mailing Address - Street 1:2500 E CAPITOL DR
Mailing Address - Street 2:SUITE 1700
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-8735
Mailing Address - Country:US
Mailing Address - Phone:920-734-9600
Mailing Address - Fax:920-734-4773
Practice Address - Street 1:2500 E CAPITOL DR
Practice Address - Street 2:SUITE 1700
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8735
Practice Address - Country:US
Practice Address - Phone:920-734-9600
Practice Address - Fax:920-734-4773
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI3159-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1710172614Medicaid
WIW12072005Medicare PIN
WIW12073005Medicare PIN
WIW12074005Medicare PIN