Provider Demographics
NPI:1073506119
Name:LUDWIKOWSKI, KATHLEEN L
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:LUDWIKOWSKI
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:N5427 COUNTY ROAD Y
Mailing Address - Street 2:
Mailing Address - City:MONTELLO
Mailing Address - State:WI
Mailing Address - Zip Code:53949-8307
Mailing Address - Country:US
Mailing Address - Phone:608-297-9680
Mailing Address - Fax:
Practice Address - Street 1:317 DEWITT ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-2155
Practice Address - Country:US
Practice Address - Phone:608-297-9680
Practice Address - Fax:608-745-1757
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4688-33363LP0200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK16052Medicare UPIN