Provider Demographics
NPI:1295792711
Name:CULLEN, KELLY ANN (DO)
Entity type:Individual
Prefix:
First Name:KELLY ANN
Middle Name:
Last Name:CULLEN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 E WISCONSIN AVE
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-4815
Mailing Address - Country:US
Mailing Address - Phone:414-290-6720
Mailing Address - Fax:414-290-6755
Practice Address - Street 1:111 E WISCONSIN AVE
Practice Address - Street 2:SUITE 2000
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-4815
Practice Address - Country:US
Practice Address - Phone:414-290-6720
Practice Address - Fax:414-290-6755
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44859-021207P00000X
IL036101865207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101865Medicaid
WI43509700Medicaid
IL930093591OtherMEDICARE RAILROAD
WI43509700Medicaid
WIF95093Medicare UPIN
IL036101865Medicaid
K00380Medicare ID - Type Unspecified