Healthcare Provider Details

I. General information

NPI: 1174580468
Provider Name (Legal Business Name): KENNETH GORDON KALINOWSKI APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 26TH ST STE 130
PRAIRIE DU SAC WI
53578-2205
US

IV. Provider business mailing address

4131 W LOOMIS RD STE 300
GREENFIELD WI
53221-2059
US

V. Phone/Fax

Practice location:
  • Phone: 414-325-7246
  • Fax: 414-325-3770
Mailing address:
  • Phone: 414-325-7246
  • Fax: 414-325-3770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7939
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number125666030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: