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General NPI Number Information
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NPI Number | 1487969291
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Entity Type | Individual
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Provider Name | WENDY CARROLL KELLY
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Gender | Female
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Dates
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Enumeration Date | 08/17/2010
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Last Update Date | 08/17/2010
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Provider Practice Location Address
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Address Line | 1320 WISCONSIN AVE
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City | RACINE
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State | WI
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Zip | 53403-1978
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Country | US
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Telephone | 262-687-2699
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Fax |
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Provider Business Mailing Address
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Address Line | 1737 PATRIOT WAY
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City | RACINE
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State | WI
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Zip | 53406-2730
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Country | US
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Telephone | 262-884-7137
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | WI
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