Provider Demographics
NPI:1083592588
Name:COLWELL, KYLIE
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:COLWELL
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 LONGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:54180-1224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1250 S EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-3514
Practice Address - Country:US
Practice Address - Phone:715-526-3107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-22
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4298-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant