Provider Demographics
NPI:1497140503
Name:PENDLETON, KELSEY PAIGE
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:PAIGE
Last Name:PENDLETON
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 1:530 N 108TH PL STE 100
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4253
Mailing Address - Country:US
Mailing Address - Phone:414-797-3551
Mailing Address - Fax:
Practice Address - Street 1:530 N 108TH PL STE 100
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4253
Practice Address - Country:US
Practice Address - Phone:414-797-3551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT209128207Q00000X
KY51558207Q00000X
WI71109-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100536030Medicaid
KY51558OtherKY LICENSE