Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | 10304 | WI |
N | 363LP0200X | Nurse Practitioner - Pediatrics | PENDING | WI |
NPI | 1013525096 |
---|---|
Provider Name | Katherine Ciminelli Waller |
First Address | Milwaukee, WI 53226-4874 |
Second Address | New Berlin, WI 53151-7494 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2020 |
Last Update Date | 01/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1013525096 | (05) | WI |