Provider Demographics
NPI:1124622550
Name:KALLIES, KIRSTEN R (CCP, LP)
Entity type:Individual
Prefix:MS
First Name:KIRSTEN
Middle Name:R
Last Name:KALLIES
Suffix:
Gender:F
Credentials:CCP, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S84W23478 SHERMAN LN
Mailing Address - Street 2:
Mailing Address - City:BIG BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53103-9233
Mailing Address - Country:US
Mailing Address - Phone:262-442-8064
Mailing Address - Fax:
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-259-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI100-018242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
089006-0653OtherAMERICAN BOARD OF CARDIOVASCULAR PERFUSION
WI100-018OtherWISCONSIN DEPARTMENT OF REGULATION AND LICENSING