Provider Demographics
NPI:1669616256
Name:MCNELLY, KIM MARIE (RN)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:MCNELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 214
Mailing Address - Street 2:
Mailing Address - City:VIOLA
Mailing Address - State:WI
Mailing Address - Zip Code:54664-0214
Mailing Address - Country:US
Mailing Address - Phone:608-625-6156
Mailing Address - Fax:
Practice Address - Street 1:1407 SAINT ANDREW ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-3301
Practice Address - Country:US
Practice Address - Phone:608-372-3145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI114163-30163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health