Healthcare Provider Details

I. General information

NPI: 1003936857
Provider Name (Legal Business Name): KELLY ANN CAROTHERS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY ANN STAUDE M.D.

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1836 SOUTH AVE
LA CROSSE WI
54601-5429
US

IV. Provider business mailing address

1836 SOUTH AVE
LA CROSSE WI
54601-5429
US

V. Phone/Fax

Practice location:
  • Phone: 608-782-7300
  • Fax:
Mailing address:
  • Phone: 608-782-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number40256
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40256
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: