Provider Demographics
NPI:1467915983
Name:RIFFEL, KELLY LYNN (APNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:RIFFEL
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6400 INDUSTRIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-2452
Mailing Address - Country:US
Mailing Address - Phone:888-334-3360
Mailing Address - Fax:414-423-4134
Practice Address - Street 1:6121 GREEN BAY RD STE 100
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2931
Practice Address - Country:US
Practice Address - Phone:262-359-1652
Practice Address - Fax:262-764-7577
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI178023-30363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100087100Medicaid