MEDICARE: MRS. KATHLEEN ANN KEPHART

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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1417251851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLEEN ANN KEPHART

Provider Business Mailing Address
First Line	:	10610 MAIN ST
Second Line	:	SUITE 224
City	:	HAYWARD
State	:	WI
Zip	:	54843-6595
Country	:	US
Telephone Number	:	715-638-3296
Fax Number	:	715-634-5387

Provider Business Practice Location Address
First Line	:	10610 MAIN ST
Second Line	:	SUITE 224
City	:	HAYWARD
State	:	WI
Zip	:	54843-6595
Country	:	US
Telephone Number	:	715-638-3296
Fax Number	:	715-634-5387

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

Provider Enumeration Date	:	12/28/2010
Last Update Date	:	12/28/2010

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