Provider Demographics
NPI:1033161708
Name:HENRICKSON, KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:HENRICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:PEDIATRIC INFECTIOUS DISEASE
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-337-7070
Mailing Address - Fax:414-337-7093
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:PEDIATRIC INFECTIOUS DISEASE
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-337-7070
Practice Address - Fax:414-337-7093
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI312142080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
002000198GOtherHUMANA
WI1033161708Medicaid
WI680862616Medicare PIN
002000198GOtherHUMANA
WI1033161708Medicaid