Provider Demographics
NPI:1639456379
Name:QUINN, KELLY R (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:QUINN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S PARK ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-290-6000
Mailing Address - Fax:608-260-2977
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:SUITE A
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:608-290-6000
Practice Address - Fax:608-260-2977
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6395-033363L00000X
NC5005348363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01773636Medicare PIN
WIK400258333Medicare PIN