Provider Demographics
NPI:1982990438
Name:MEIDENBAUER, KELLY MARIE (BS)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:MEIDENBAUER
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 N. 51ST BLVD.
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218
Mailing Address - Country:US
Mailing Address - Phone:414-527-6970
Mailing Address - Fax:414-527-6971
Practice Address - Street 1:5555 N. 51ST BLVD.
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218
Practice Address - Country:US
Practice Address - Phone:414-527-6970
Practice Address - Fax:414-527-6971
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator