Provider Demographics
NPI:1376710251
Name:DITTBERNER, KELLY LEE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LEE
Last Name:DITTBERNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W12250 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:WI
Mailing Address - Zip Code:53555-9329
Mailing Address - Country:US
Mailing Address - Phone:608-516-9337
Mailing Address - Fax:608-592-5818
Practice Address - Street 1:215 NORTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9294
Practice Address - Country:US
Practice Address - Phone:608-516-9337
Practice Address - Fax:608-745-0333
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-10
Last Update Date:2008-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health