Healthcare Provider Details

I. General information

NPI: 1962444265
Provider Name (Legal Business Name): KELLE FECKER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 PINE RIDGE BLVD STE 211
WAUSAU WI
54401
US

IV. Provider business mailing address

425 PINE RIDGE BLVD STE 211
WAUSAU WI
54401
US

V. Phone/Fax

Practice location:
  • Phone: 715-845-5505
  • Fax: 715-848-2884
Mailing address:
  • Phone: 715-845-5505
  • Fax: 715-848-2884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number145896030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: