Provider Demographics
NPI:1043605512
Name:MCKENNA, KAITLIN MARIE (DO)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARIE
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:MARIE
Other - Last Name:STATZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 778789
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8789
Mailing Address - Country:US
Mailing Address - Phone:414-672-1353
Mailing Address - Fax:
Practice Address - Street 1:1032 S CESAR E CHAVEZ DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-2203
Practice Address - Country:US
Practice Address - Phone:414-672-1353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI66342208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043605512Medicaid