Healthcare Provider Details

I. General information

NPI: 1487952388
Provider Name (Legal Business Name): MICHELE KASTEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2011
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 SUNSET BEACH RD
SUAMICO WI
54173-8220
US

IV. Provider business mailing address

3702 IVES LN
SUAMICO WI
54173-7714
US

V. Phone/Fax

Practice location:
  • Phone: 920-366-8889
  • Fax:
Mailing address:
  • Phone: 920-366-8889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberDOGD-8449RB
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: