Provider Demographics
NPI:1649321498
Name:LAGROW, KIMBERLY ANN (RN, FNP-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:LAGROW
Suffix:
Gender:F
Credentials:RN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W125S6729 JO CT
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-3512
Mailing Address - Country:US
Mailing Address - Phone:262-893-2645
Mailing Address - Fax:
Practice Address - Street 1:W125S6729 JO CT
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150-3512
Practice Address - Country:US
Practice Address - Phone:262-893-2645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI130133-030163WH0200X, 163W00000X
WI7506363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39912500Medicaid