Provider Demographics
NPI:1437842291
Name:WISNIESKI, KATELYN
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:WISNIESKI
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 1:1721 COLFAX ST
Mailing Address - Street 2:
Mailing Address - City:SCHUYLER
Mailing Address - State:NE
Mailing Address - Zip Code:68661-1400
Mailing Address - Country:US
Mailing Address - Phone:402-352-3745
Mailing Address - Fax:402-352-8750
Practice Address - Street 1:1721 COLFAX ST
Practice Address - Street 2:
Practice Address - City:SCHUYLER
Practice Address - State:NE
Practice Address - Zip Code:68661-1400
Practice Address - Country:US
Practice Address - Phone:402-352-3745
Practice Address - Fax:402-352-8750
Is Sole Proprietor?:No
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2929363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant