Provider Demographics
NPI:1114411956
Name:DILLIARD, KELLEY NICOLE (DO)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:NICOLE
Last Name:DILLIARD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 PLAZA DR STE 1300
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4165
Mailing Address - Country:US
Mailing Address - Phone:715-847-2630
Mailing Address - Fax:
Practice Address - Street 1:2720 PLAZA DR STE 1300
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4165
Practice Address - Country:US
Practice Address - Phone:715-847-2630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036153728207Q00000X
WI75853-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine