Provider Demographics
NPI:1619306297
Name:PENNENBERG, KRISTI R (APNP)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:R
Last Name:PENNENBERG
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:KRISTI
Other - Middle Name:R
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APNP
Mailing Address - Street 1:PO BOX 735041
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5041
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-05
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5560363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100034606Medicaid
WI1619306297OtherNPI