Provider Demographics
NPI:1851642128
Name:KILEY, KATELYN M (PA-C)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:M
Last Name:KILEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2379 JOURDAIN LN
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2137
Mailing Address - Country:US
Mailing Address - Phone:920-737-9504
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:STE 340
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311
Practice Address - Country:US
Practice Address - Phone:920-288-8377
Practice Address - Fax:920-288-8385
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3030363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI71460Medicare PIN
WI07650Medicare PIN