Provider Demographics
NPI:1700414091
Name:PELLICANO, KAITLIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KAITLIN
Middle Name:
Last Name:PELLICANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:262-741-2121
Mailing Address - Fax:
Practice Address - Street 1:W3985 COUNTY ROAD NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4337
Practice Address - Country:US
Practice Address - Phone:262-741-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI76460-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine