Provider Demographics
NPI:1750913844
Name:KERKENBUSH, KELLY A
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:KERKENBUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1023 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-6559
Mailing Address - Country:US
Mailing Address - Phone:414-617-8837
Mailing Address - Fax:
Practice Address - Street 1:1023 W 5TH ST
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-6559
Practice Address - Country:US
Practice Address - Phone:414-617-8837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program