MEDICARE: KELLY WEISSE R.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	185704-30	WI

General Provider Information

NPI Number	:	1194156794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY WEISSE R.N.

Provider Business Mailing Address
First Line	:	322 WASHBURN RD
Second Line	:
City	:	DEERFIELD
State	:	WI
Zip	:	53531-9577
Country	:	US
Telephone Number	:	608-764-1492
Fax Number	:

Provider Business Practice Location Address
First Line	:	322 WASHBURN RD
Second Line	:
City	:	DEERFIELD
State	:	WI
Zip	:	53531-9577
Country	:	US
Telephone Number	:	608-764-1492
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/06/2013
Last Update Date	:	12/06/2013

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