Provider Demographics
NPI:1962444265
Name:FECKER, KELLE (CRNA)
Entity Type:Individual
Prefix:MS
First Name:KELLE
Middle Name:
Last Name:FECKER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 PINE RIDGE BLVD
Mailing Address - Street 2:STE 211
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401
Mailing Address - Country:US
Mailing Address - Phone:715-845-5505
Mailing Address - Fax:715-848-2884
Practice Address - Street 1:425 PINE RIDGE BLVD
Practice Address - Street 2:STE 211
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401
Practice Address - Country:US
Practice Address - Phone:715-845-5505
Practice Address - Fax:715-848-2884
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI145896030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI88792OtherSECURITY HEALTH PLAN
WISWOPEOtherWPS
WI44326600OtherMANAGED HEALTH CARE
WI391330887OtherASSOCIATES FOR HEALTHCARE
WI003921305OtherHUMAN GOLD MEDICARE
WI44326600Medicaid
WIP00088510OtherMEDICARE RAILROAD
WI88792OtherSECURITY HEALTH MEDICAID
WI88792OtherSECURITY HEALTH MEDICAID
WI44326600OtherMANAGED HEALTH CARE