Provider Demographics
NPI:1992595318
Name:SCROGGINS, KELLY DENISE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DENISE
Last Name:SCROGGINS
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 1:2501 JEAN AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404-1819
Mailing Address - Country:US
Mailing Address - Phone:262-744-5362
Mailing Address - Fax:262-744-5362
Practice Address - Street 1:2501 JEAN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53404-1819
Practice Address - Country:US
Practice Address - Phone:262-744-5362
Practice Address - Fax:262-744-5362
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home