Provider Demographics
NPI:1609544717
Name:DECLEENE, KATHRYN MARY
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARY
Last Name:DECLEENE
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 1:5816 ALBRIGHT CT
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-5045
Mailing Address - Country:US
Mailing Address - Phone:920-851-4302
Mailing Address - Fax:
Practice Address - Street 1:6936 PINE ARBOR DR S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-4645
Practice Address - Country:US
Practice Address - Phone:651-326-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-02
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program