Provider Demographics
NPI:1700591344
Name:EHLERT, MIKAYLA NICOLE (AA)
Entity type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:NICOLE
Last Name:EHLERT
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2901 W KINNICKINNIC RIVER PKWY STE 305
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-3660
Mailing Address - Country:US
Mailing Address - Phone:414-649-6000
Mailing Address - Fax:
Practice Address - Street 1:36500 AURORA DR
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:WI
Practice Address - Zip Code:53066-4899
Practice Address - Country:US
Practice Address - Phone:262-434-1000
Practice Address - Fax:262-434-5050
Is Sole Proprietor?:No
Enumeration Date:2023-01-18
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI514-017367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100229331Medicaid