Provider Demographics
NPI:1902057052
Name:ANDERSON-KIM, SARA J (APNP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:J
Last Name:ANDERSON-KIM
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-9000
Mailing Address - Fax:
Practice Address - Street 1:752 N HIGH POINT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-2236
Practice Address - Country:US
Practice Address - Phone:608-824-4000
Practice Address - Fax:608-824-4956
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.007242363LF0000X
WI9754363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1902057052Medicaid