Provider Demographics
NPI:1578368700
Name:KEITH, KIMBERLY ANN (PMHNP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:KEITH
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11321 64TH ST S
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-9588
Mailing Address - Country:US
Mailing Address - Phone:715-741-0500
Mailing Address - Fax:
Practice Address - Street 1:320 W GRAND AVE STE 204
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54495-2781
Practice Address - Country:US
Practice Address - Phone:715-421-1107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-13
Last Update Date:2025-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2024106812363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health