Provider Demographics
NPI:1720420391
Name:MOLDENHAUER, KIMBERLY (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MOLDENHAUER
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 1:23 W SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-2342
Mailing Address - Country:US
Mailing Address - Phone:920-926-0101
Mailing Address - Fax:
Practice Address - Street 1:23 W SCOTT ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-2342
Practice Address - Country:US
Practice Address - Phone:920-926-0101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-24
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI143118363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner