Provider Demographics
NPI:1083985279
Name:KELLNER, MARY CATHERINE (RN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:CATHERINE
Last Name:KELLNER
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 1:2007 HERMITAGE LN
Mailing Address - Street 2:APT. 103
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-3124
Mailing Address - Country:US
Mailing Address - Phone:608-563-0948
Mailing Address - Fax:
Practice Address - Street 1:2007 HERMITAGE LN
Practice Address - Street 2:APT 103
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-3124
Practice Address - Country:US
Practice Address - Phone:608-563-0948
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI106569030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse