Provider Demographics
NPI:1245477801
Name:LEDERHAUS, KIM N
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:N
Last Name:LEDERHAUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 DEERWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-1601
Mailing Address - Country:US
Mailing Address - Phone:920-751-9600
Mailing Address - Fax:
Practice Address - Street 1:740 DEERWOOD AVE
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-1601
Practice Address - Country:US
Practice Address - Phone:920-751-9600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-19
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI131926363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1245477801Medicaid
WI710180641Medicare PIN
WI453000604Medicare PIN