Provider Demographics
NPI:1770968760
Name:KAMALI, ESMAEIL BEN (FNP)
Entity type:Individual
Prefix:
First Name:ESMAEIL
Middle Name:BEN
Last Name:KAMALI
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3505
Mailing Address - Country:US
Mailing Address - Phone:678-779-7038
Mailing Address - Fax:
Practice Address - Street 1:725 S WEBSTER AVE STE 201
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3500
Practice Address - Country:US
Practice Address - Phone:920-430-7100
Practice Address - Fax:920-430-7114
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-20
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6627-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400254773Medicare Oscar/Certification