Provider Demographics
NPI:1851623474
Name:AUGUSTINE, KIM ANN (112279-030)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:ANN
Last Name:AUGUSTINE
Suffix:
Gender:F
Credentials:112279-030
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4306 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1913
Mailing Address - Country:US
Mailing Address - Phone:262-498-1613
Mailing Address - Fax:
Practice Address - Street 1:4306 31ST AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1913
Practice Address - Country:US
Practice Address - Phone:262-498-1613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-06
Last Update Date:2010-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI112279-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse