Provider Demographics
NPI:1063433316
Name:KALK, GRACE LORRAINE (PA)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:LORRAINE
Last Name:KALK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:OCONTO
Mailing Address - State:WI
Mailing Address - Zip Code:54153-1080
Mailing Address - Country:US
Mailing Address - Phone:920-834-4110
Mailing Address - Fax:
Practice Address - Street 1:940 S SAINT AUGUSTINE ST
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:WI
Practice Address - Zip Code:54162-9453
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:920-496-4705
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42985400Medicaid
WI42985400Medicaid
07555-0003Medicare ID - Type Unspecified