MEDICARE: MRS. KELLY JO KOPACZ RN

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	163W00000X	Registered Nurse		WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	38326200	OTHER	WI	PROVIDER NUMBER

General Provider Information

NPI Number	:	1235265000
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY JO KOPACZ RN

Provider Business Mailing Address
First Line	:	665 140TH ST
Second Line	:
City	:	ROBERTS
State	:	WI
Zip	:	54023
Country	:	US
Telephone Number	:	715-749-4492
Fax Number	:

Provider Business Practice Location Address
First Line	:	N750 DOUG BLEGEN DR
Second Line	:
City	:	SPRING VALLEY
State	:	WI
Zip	:	54767-8806
Country	:	US
Telephone Number	:	715-778-4301
Fax Number	:

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

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	07/08/2007

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