Provider Demographics
NPI:1780771261
Name:KELLERMANN, KELSY B (PA)
Entity type:Individual
Prefix:
First Name:KELSY
Middle Name:B
Last Name:KELLERMANN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELSY
Other - Middle Name:B
Other - Last Name:HARPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1821 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2253
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:920-431-3769
Practice Address - Street 1:1821 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2253
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:920-431-3769
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00373789OtherRAILROAD
WI42895200Medicaid
WI004271460Medicare PIN
WI42895200Medicaid