Provider Demographics
NPI:1659798908
Name:LIZIK, KYRIE (CAC, WCMT, MSOM)
Entity Type:Individual
Prefix:
First Name:KYRIE
Middle Name:
Last Name:LIZIK
Suffix:
Gender:F
Credentials:CAC, WCMT, MSOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 MINZ PARK CIR
Mailing Address - Street 2:#2
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-5738
Mailing Address - Country:US
Mailing Address - Phone:414-241-6415
Mailing Address - Fax:
Practice Address - Street 1:1414 E PARADISE DR
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-5426
Practice Address - Country:US
Practice Address - Phone:262-323-9022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI628-55171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist