Provider Demographics
NPI:1649583980
Name:IZYK, KELI A (RN)
Entity Type:Individual
Prefix:
First Name:KELI
Middle Name:A
Last Name:IZYK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3686 SHORE RD
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-8242
Mailing Address - Country:US
Mailing Address - Phone:920-743-3956
Mailing Address - Fax:
Practice Address - Street 1:3686 SHORE RD
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-8242
Practice Address - Country:US
Practice Address - Phone:920-743-3956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI312900-31164W00000X
WI179456-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse