Provider Demographics
NPI:1356691604
Name:CHERNE, KELLY M (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:CHERNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:GOALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 8031
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8031
Mailing Address - Country:US
Mailing Address - Phone:866-313-0337
Mailing Address - Fax:920-739-0124
Practice Address - Street 1:820 E GRANT ST STE 230
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911-3441
Practice Address - Country:US
Practice Address - Phone:920-738-7300
Practice Address - Fax:920-738-7301
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI300223363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant