Healthcare Provider Details

I. General information

NPI: 1477643807
Provider Name (Legal Business Name): KELLI K PETTIT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS KELLI KREUL

II. Dates (important events)

Enumeration Date: 10/14/2006
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DELAFIELD ST, STE 209
WAUKESHA WI
53188-3403
US

IV. Provider business mailing address

1111 DELAFIELD ST, STE 209
WAUKESHA WI
53188-3403
US

V. Phone/Fax

Practice location:
  • Phone: 262-542-0444
  • Fax: 262-542-8214
Mailing address:
  • Phone: 262-542-0444
  • Fax: 262-542-8214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number48072-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number48072-020
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number48072-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: