Provider Demographics
NPI:1568195899
Name:PETHAN, KRISTEN ANNE (CPM)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANNE
Last Name:PETHAN
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W2774 E JEFFERSON RD
Mailing Address - Street 2:
Mailing Address - City:CHILTON
Mailing Address - State:WI
Mailing Address - Zip Code:53014-9670
Mailing Address - Country:US
Mailing Address - Phone:608-206-1493
Mailing Address - Fax:
Practice Address - Street 1:1230 W COLLEGE AVE STE C
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-5287
Practice Address - Country:US
Practice Address - Phone:920-574-3074
Practice Address - Fax:920-574-9502
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty