=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760042923
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY RAE VANDERMUSS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2019
-----------------------------------------------------
Last Update Date | 12/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1381 BRAYDEN LN
-----------------------------------------------------
City | DE PERE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54115-9249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-664-3734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2502 S ASHLAND AVE
-----------------------------------------------------
City | GREEN BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54304-5252
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-496-4700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 4704-23
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------