Provider Demographics
NPI:1134501190
Name:KIENERT, KELSEY (MD)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:KIENERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:MARKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:101 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2570
Mailing Address - Country:US
Mailing Address - Phone:920-720-1463
Mailing Address - Fax:
Practice Address - Street 1:101 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956
Practice Address - Country:US
Practice Address - Phone:920-720-1463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-25
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI68772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100080233Medicaid