Provider Demographics
NPI:1104211374
Name:DEANGELI, KATHERINE M (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:M
Last Name:DEANGELI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 E MILESTONE DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-6701
Mailing Address - Country:US
Mailing Address - Phone:920-731-8131
Mailing Address - Fax:920-832-0444
Practice Address - Street 1:2500 E CAPITOL DR STE 1700
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-8735
Practice Address - Country:US
Practice Address - Phone:920-731-8131
Practice Address - Fax:920-832-0444
Is Sole Proprietor?:No
Enumeration Date:2015-04-03
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI77316-20208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100211567Medicaid
WI77316-20OtherLICENSE