Healthcare Provider Details

I. General information

NPI: 1053136481
Provider Name (Legal Business Name): KELLY MARIE BUBLITZ APNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13133 N PORT WASHINGTON RD STE 204
MEQUON WI
53097-2420
US

IV. Provider business mailing address

1608 BEHRENS DR
CEDARBURG WI
53012-8870
US

V. Phone/Fax

Practice location:
  • Phone: 262-243-2524
  • Fax:
Mailing address:
  • Phone: 262-339-5809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number16214-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: