Basic Information
| Provider Information | |||||||||
| NPI: | 1710073218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COX | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | TWIN PORTS CLINIC VA | ||||||||
| Address2: | 3520 TOWER AVE. | ||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153982469 | ||||||||
| FaxNumber: | 2187284404 | ||||||||
| Practice Location | |||||||||
| Address1: | TWIN PORTS CLINIC VA | ||||||||
| Address2: | 3520 TOWER AVE. | ||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153982469 | ||||||||
| FaxNumber: | 2187284404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | R0990848 | MN | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 060020200 | 05 | MN | MEDICAID |