Provider Demographics
NPI:1043933021
Name:IBIZA, KELLEN JOSEPH (CNC)
Entity Type:Individual
Prefix:MR
First Name:KELLEN
Middle Name:JOSEPH
Last Name:IBIZA
Suffix:
Gender:M
Credentials:CNC
Other - Prefix:MR
Other - First Name:KJ
Other - Middle Name:
Other - Last Name:BRADFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:108 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53153-9791
Mailing Address - Country:US
Mailing Address - Phone:312-826-6073
Mailing Address - Fax:
Practice Address - Street 1:108 N HARRISON ST
Practice Address - Street 2:
Practice Address - City:NORTH PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53153-9791
Practice Address - Country:US
Practice Address - Phone:312-826-6073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach