Healthcare Provider Details

I. General information

NPI: 1235601709
Provider Name (Legal Business Name): KARA DANIELLE MCCLONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 S 41ST ST
MANITOWOC WI
54220-7316
US

IV. Provider business mailing address

PO BOX 2290
MANITOWOC WI
54221-2290
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-5241
  • Fax:
Mailing address:
  • Phone: 920-320-5241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: