Provider Demographics
NPI:1265863906
Name:RAFFERTY, KELLY (LPN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RAFFERTY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4690 WINDING CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:ABRAMS
Mailing Address - State:WI
Mailing Address - Zip Code:54101-9576
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4690 WINDING CREEK TRL
Practice Address - Street 2:
Practice Address - City:ABRAMS
Practice Address - State:WI
Practice Address - Zip Code:54101-9576
Practice Address - Country:US
Practice Address - Phone:920-819-6197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI302119-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse