Provider Demographics
NPI:1972717460
Name:FITZGERALD, KIMBERLY ANN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ANN
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 S MAIN ST STE 120
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-6116
Mailing Address - Country:US
Mailing Address - Phone:920-322-0447
Mailing Address - Fax:920-322-1362
Practice Address - Street 1:845 S MAIN ST STE 120
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-6116
Practice Address - Country:US
Practice Address - Phone:920-322-0447
Practice Address - Fax:920-322-1362
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4507-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41043800Medicaid