Healthcare Provider Details

I. General information

NPI: 1760233795
Provider Name (Legal Business Name): KELLY HOFSTETTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4958 INNOVATION DR APT 430
DEFOREST WI
53532-2840
US

IV. Provider business mailing address

4958 INNOVATION DR APT 430
DEFOREST WI
53532-2840
US

V. Phone/Fax

Practice location:
  • Phone: 715-367-0808
  • Fax:
Mailing address:
  • Phone: 715-367-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number255227
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: