Provider Demographics
NPI:1083398929
Name:WALKER, KELLIE (RN)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6832 S EAST LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE NEBAGAMON
Mailing Address - State:WI
Mailing Address - Zip Code:54849-9107
Mailing Address - Country:US
Mailing Address - Phone:218-355-8268
Mailing Address - Fax:
Practice Address - Street 1:6832 S EAST LAKE BLVD
Practice Address - Street 2:
Practice Address - City:LAKE NEBAGAMON
Practice Address - State:WI
Practice Address - Zip Code:54849-9107
Practice Address - Country:US
Practice Address - Phone:218-355-8268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI195210-30163WH0200X
MNR211842-4163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WH0200XNursing Service ProvidersRegistered NurseHome Health