Provider Demographics
NPI:1306369848
Name:WELLNITZ, KYA LEE (LPN)
Entity Type:Individual
Prefix:MISS
First Name:KYA
Middle Name:LEE
Last Name:WELLNITZ
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:N2860 MODE LN
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-8820
Mailing Address - Country:US
Mailing Address - Phone:920-397-0791
Mailing Address - Fax:
Practice Address - Street 1:299 SWEET GRASS DR
Practice Address - Street 2:
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590-3468
Practice Address - Country:US
Practice Address - Phone:608-825-4474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI32171431164W00000X
WI321714-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse