Healthcare Provider Details

I. General information

NPI: 1154077949
Provider Name (Legal Business Name): KELSEY HINTERLEITNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELSEY CHIOLINO

II. Dates (important events)

Enumeration Date: 03/01/2022
Last Update Date: 02/10/2024
Certification Date: 02/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 ELM ST
WOODRUFF WI
54568-9100
US

IV. Provider business mailing address

1280 ARROWHEAD DR
ARBOR VITAE WI
54568-9701
US

V. Phone/Fax

Practice location:
  • Phone: 715-661-0639
  • Fax:
Mailing address:
  • Phone: 715-661-0639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1003312
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number6580-403
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: