Provider Demographics
NPI:1477643807
Name:PETTIT, KELLI K (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:K
Last Name:PETTIT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:KREUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1111 DELAFIELD ST,
Mailing Address - Street 2:STE 209
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3403
Mailing Address - Country:US
Mailing Address - Phone:262-542-0444
Mailing Address - Fax:262-542-8214
Practice Address - Street 1:1111 DELAFIELD ST,
Practice Address - Street 2:STE 209
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3403
Practice Address - Country:US
Practice Address - Phone:262-542-0444
Practice Address - Fax:262-542-8214
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48072-0202086S0129X, 2086X0206X, 208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1477643807Medicaid