Healthcare Provider Details

I. General information

NPI: 1669473674
Provider Name (Legal Business Name): KAY ELLEN THEYERL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 THEDA CLARK MEDICAL PLZ SUITE 240
NEENAH WI
54956-2721
US

IV. Provider business mailing address

PO BOX 8003
APPLETON WI
54912-8003
US

V. Phone/Fax

Practice location:
  • Phone: 920-725-2070
  • Fax: 920-725-4549
Mailing address:
  • Phone: 920-996-3200
  • Fax: 920-738-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number46219-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: