Provider Demographics
NPI:1225557457
Name:WATRAS, KELLY IRENE (MT)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:IRENE
Last Name:WATRAS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7862 COUNTY ROAD H
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:WI
Mailing Address - Zip Code:54940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:W6905 PARKVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:WI
Practice Address - Zip Code:54942
Practice Address - Country:US
Practice Address - Phone:920-757-9887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13809-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist