Provider Demographics
NPI:1376592543
Name:WISCH, KELLY M (NP)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:M
Last Name:WISCH
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:1300 S CENTURY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUNAKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53597-2386
Mailing Address - Country:US
Mailing Address - Phone:608-849-4315
Mailing Address - Fax:608-850-1606
Practice Address - Street 1:1300 S CENTURY AVE
Practice Address - Street 2:
Practice Address - City:WAUNAKEE
Practice Address - State:WI
Practice Address - Zip Code:53597-2386
Practice Address - Country:US
Practice Address - Phone:608-849-4315
Practice Address - Fax:608-850-1606
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-08-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI2345-033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1376592543Medicaid