Healthcare Provider Details

I. General information

NPI: 1821472226
Provider Name (Legal Business Name): KELLY THEODORE PMHNP, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E WISCONSIN AVE STE 1500
MILWAUKEE WI
53202-4808
US

IV. Provider business mailing address

4800 N SCOTTSDALE RD STE 2500
SCOTTSDALE AZ
85251-7630
US

V. Phone/Fax

Practice location:
  • Phone: 262-999-3495
  • Fax:
Mailing address:
  • Phone: 262-999-3495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number6467
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6467
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: