Provider Demographics
NPI:1013668797
Name:WEMKEN, KELLY MARIE
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MARIE
Last Name:WEMKEN
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 1:4300 58TH ST N APT 1808
Mailing Address - Street 2:
Mailing Address - City:KENNETH CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33709-5343
Mailing Address - Country:US
Mailing Address - Phone:847-450-8414
Mailing Address - Fax:
Practice Address - Street 1:4300 58TH ST N APT 1808
Practice Address - Street 2:
Practice Address - City:KENNETH CITY
Practice Address - State:FL
Practice Address - Zip Code:33709-5343
Practice Address - Country:US
Practice Address - Phone:847-450-8414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date: