Healthcare Provider Details

I. General information

NPI: 1215271994
Provider Name (Legal Business Name): KELLY A KRISTBAUM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY A WASZAK

II. Dates (important events)

Enumeration Date: 11/19/2012
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 W KINNICKINNIC RIVER PKWY
MILWAUKEE WI
53215-3677
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-3750
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5165
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number154594
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: