Provider Demographics
NPI:1760856546
Name:WOPPERT, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WOPPERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N51 W24953 LISBON ROAD
Mailing Address - Street 2:FASTCARE
Mailing Address - City:SUSSEX
Mailing Address - State:WI
Mailing Address - Zip Code:53089-2677
Mailing Address - Country:US
Mailing Address - Phone:262-532-8690
Mailing Address - Fax:
Practice Address - Street 1:N66W25201 COUNTY HIGHWAY VV
Practice Address - Street 2:FASTCARE
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-2677
Practice Address - Country:US
Practice Address - Phone:262-532-8690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6722-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily