Provider Demographics
NPI:1194156794
Name:WEISSE, KELLY (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WEISSE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 WASHBURN RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53531-9577
Mailing Address - Country:US
Mailing Address - Phone:608-764-1492
Mailing Address - Fax:
Practice Address - Street 1:322 WASHBURN RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:WI
Practice Address - Zip Code:53531-9577
Practice Address - Country:US
Practice Address - Phone:608-764-1492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI185704-30163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice