Provider Demographics
NPI:1194914499
Name:KELLEY, ELIZABETH KATHLEEN (LPN/RCS)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:KATHLEEN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LPN/RCS
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:KATHLEEN
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN/RCS
Mailing Address - Street 1:W4764 HIDDEN PINE LN
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-1650
Mailing Address - Country:US
Mailing Address - Phone:920-858-2682
Mailing Address - Fax:715-745-2957
Practice Address - Street 1:W4764 HIDDEN PINE LN
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-1650
Practice Address - Country:US
Practice Address - Phone:920-858-2682
Practice Address - Fax:715-745-2957
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27691-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38275700Medicaid