Provider Demographics
NPI:1538462650
Name:QUANDT, KELLY MARIE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MARIE
Last Name:QUANDT
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:11270 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-3410
Practice Address - Country:US
Practice Address - Phone:262-241-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-11
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4290-33363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100014882Medicaid