Provider Demographics
NPI:1154014587
Name:WISOWATY, KAYLA
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:WISOWATY
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 1:10200 W INNOVATION DR STE 400
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4826
Mailing Address - Country:US
Mailing Address - Phone:414-944-2000
Mailing Address - Fax:
Practice Address - Street 1:10200 W INNOVATION DR STE 400
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4826
Practice Address - Country:US
Practice Address - Phone:414-944-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2023003353363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily