Provider Demographics
NPI:1073700241
Name:KRUEGER, KATHLEEN
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:
Last Name:KRUEGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1246 S 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-5922
Mailing Address - Country:US
Mailing Address - Phone:715-842-8476
Mailing Address - Fax:
Practice Address - Street 1:1246 S 11TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-5922
Practice Address - Country:US
Practice Address - Phone:715-842-8476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI103554172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41486400Medicaid