Provider Demographics
NPI:1740281401
Name:PICKENS, KELLY A (APNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:PICKENS
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2917 INTERNATIONAL LN
Mailing Address - Street 2:PO BOX 14017
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-3135
Mailing Address - Country:US
Mailing Address - Phone:608-245-3354
Mailing Address - Fax:866-903-5812
Practice Address - Street 1:301 E 2ND ST
Practice Address - Street 2:
Practice Address - City:RICHLAND CENTER
Practice Address - State:WI
Practice Address - Zip Code:53581-1900
Practice Address - Country:US
Practice Address - Phone:608-647-6161
Practice Address - Fax:608-647-3178
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2602363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41264700Medicaid
WI0852480001OtherDMERC
WI0852480001OtherDMERC
WI41264700Medicaid
WI001457060Medicare PIN