Provider Demographics
NPI:1275542326
Name:CERTALIC, KIRSTIN M (DO)
Entity Type:Individual
Prefix:DR
First Name:KIRSTIN
Middle Name:M
Last Name:CERTALIC
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIRSTIN
Other - Middle Name:MAUREEN
Other - Last Name:CROWE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2315 E MORELAND BLVD
Mailing Address - Street 2:WESTBROOK WALK-IN CLINIC
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-2939
Mailing Address - Country:US
Mailing Address - Phone:262-532-5800
Mailing Address - Fax:262-532-5760
Practice Address - Street 1:2315 E MORELAND BLVD
Practice Address - Street 2:WESTBROOK WALK-IN CLINIC
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-2939
Practice Address - Country:US
Practice Address - Phone:262-532-5800
Practice Address - Fax:262-532-5760
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40646207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1275542326Medicaid
WI30091900Medicaid
BC6171932OtherDEA NUMBER
WI30091900Medicaid
WI680860595Medicare PIN
52535-0028Medicare ID - Type UnspecifiedMEDICARE PROVIDER
WI736011615Medicare PIN