Provider Demographics
NPI:1417189135
Name:KLEIN, KEVIN K (NP)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:K
Last Name:KLEIN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 SOUTH DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINNEBAGO
Mailing Address - State:WI
Mailing Address - Zip Code:54985-0009
Mailing Address - Country:US
Mailing Address - Phone:920-235-4910
Mailing Address - Fax:920-237-2043
Practice Address - Street 1:1300 SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985-0009
Practice Address - Country:US
Practice Address - Phone:920-235-4910
Practice Address - Fax:920-237-2043
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI151309363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner