Provider Demographics
NPI:1174176812
Name:ERIKS CLINE, KYLE M (NP)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:M
Last Name:ERIKS CLINE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19070
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54307-9070
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:1860 SHAWANO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2667
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177643363LF0000X
WI21255-875363LF0000X
WI11399-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100182260Medicaid