Provider Demographics
NPI:1497393250
Name:PONCEK, KAYLA MICHELLE
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:MICHELLE
Last Name:PONCEK
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 1:3564 DRISCOLL RD APT 12
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-3675
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1630 CHIPPEWA DR
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-9503
Practice Address - Country:US
Practice Address - Phone:715-361-5480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-11
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9792363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner