Provider Demographics
NPI:1154982296
Name:DERLEIN, KELLY M (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:DERLEIN
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:JONAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNPC-AG
Mailing Address - Street 1:1000 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-5703
Mailing Address - Country:US
Mailing Address - Phone:715-387-5511
Mailing Address - Fax:
Practice Address - Street 1:3400 MINISTRY PKWY
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-5220
Practice Address - Country:US
Practice Address - Phone:715-393-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI936233363LA2100X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care