Provider Demographics
NPI:1053076729
Name:KENSMOE, BAILEE (RPH)
Entity Type:Individual
Prefix:
First Name:BAILEE
Middle Name:
Last Name:KENSMOE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-3748
Mailing Address - Country:US
Mailing Address - Phone:920-261-1900
Mailing Address - Fax:920-261-1910
Practice Address - Street 1:204 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-3748
Practice Address - Country:US
Practice Address - Phone:920-261-1900
Practice Address - Fax:920-261-1910
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20645-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist