Provider Demographics
NPI:1023197571
Name:WAHLEN, KELLY JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JEAN
Last Name:WAHLEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:HOAGLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1115 E LEXINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH BAY
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5383
Mailing Address - Country:US
Mailing Address - Phone:617-869-3163
Mailing Address - Fax:
Practice Address - Street 1:221 LONGWOOD AVE
Practice Address - Street 2:DEPARTMETN OF PSYCHIATRY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5804
Practice Address - Country:US
Practice Address - Phone:617-667-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2249562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry