Provider Demographics
NPI:1265688808
Name:VENESS, KALI E (PA)
Entity Type:Individual
Prefix:
First Name:KALI
Middle Name:E
Last Name:VENESS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5416
Mailing Address - Country:US
Mailing Address - Phone:260-422-4096
Mailing Address - Fax:
Practice Address - Street 1:2930 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5416
Practice Address - Country:US
Practice Address - Phone:260-422-4096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001002A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant