Provider Demographics
NPI:1912959776
Name:KING, KATHY JO (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:JO
Last Name:KING
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 CHICORY RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1615
Mailing Address - Country:US
Mailing Address - Phone:262-763-9605
Mailing Address - Fax:
Practice Address - Street 1:2805 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-9148
Practice Address - Country:US
Practice Address - Phone:262-763-5025
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31012-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38244900Medicaid