Healthcare Provider Details

I. General information

NPI: 1407800774
Provider Name (Legal Business Name): KATHY JOY KOWALKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36500 AURORA DR. SUITE 430 AURORA MEDICAL CENTER
SUMMIT WI
53066
US

IV. Provider business mailing address

36500 AURORA DR. SUITE 430 AURORA MEDICAL CENTER
SUMMIT WI
53066
US

V. Phone/Fax

Practice location:
  • Phone: 414-454-6779
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number32114
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: