Healthcare Provider Details

I. General information

NPI: 1336398122
Provider Name (Legal Business Name): KATHLEEN ANN KANE MSOM, DIPL.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300B E SUMMIT AVE
WALES WI
53183-9664
US

IV. Provider business mailing address

300B E SUMMIT AVE
WALES WI
53183-9664
US

V. Phone/Fax

Practice location:
  • Phone: 262-968-1825
  • Fax:
Mailing address:
  • Phone: 262-968-1825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number449-055
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: