Provider Demographics
NPI:1578829792
Name:SELLERS, KELLY ANN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:SELLERS
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 1:3596 E NORWICH CT
Mailing Address - Street 2:
Mailing Address - City:ST FRANCIS
Mailing Address - State:WI
Mailing Address - Zip Code:53235-4803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1845 N FARWELL AVE STE 200
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-1715
Practice Address - Country:US
Practice Address - Phone:414-225-4478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13199-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist