Provider Demographics
NPI:1487010393
Name:HEATH, KELSEY (NP)
Entity Type:Individual
Prefix:MS
First Name:KELSEY
Middle Name:
Last Name:HEATH
Suffix:
Gender:F
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:N9254 LAURA ST
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-2898
Mailing Address - Country:US
Mailing Address - Phone:920-944-2321
Mailing Address - Fax:
Practice Address - Street 1:N9254 LAURA ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54915-2898
Practice Address - Country:US
Practice Address - Phone:920-944-2321
Practice Address - Fax:920-944-2352
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP131979363LF0000X
WI14464-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX369345909Medicaid
TX369345908Medicaid