Provider Demographics
NPI:1851977854
Name:WOLLENBERG, KEVYN ALEXIS JANICEK
Entity Type:Individual
Prefix:
First Name:KEVYN
Middle Name:ALEXIS JANICEK
Last Name:WOLLENBERG
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 1:1330 214TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-1068
Mailing Address - Country:US
Mailing Address - Phone:440-785-4701
Mailing Address - Fax:
Practice Address - Street 1:535 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-1449
Practice Address - Country:US
Practice Address - Phone:715-243-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-20
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5868-23363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program