Provider Demographics
NPI:1184993768
Name:GLODOWSKI, KELLY M (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:GLODOWSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:ABRAHAMSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:2901 W KINNICKINNIC RIVER PKWY STE 101
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-649-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-28
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2756363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100021323Medicaid