Provider Demographics
NPI:1306461769
Name:PENZI, RAELEE
Entity type:Individual
Prefix:
First Name:RAELEE
Middle Name:
Last Name:PENZI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAELEE
Other - Middle Name:
Other - Last Name:CIRIACKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2416 SPRINGDALE RD APT 205
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-2738
Mailing Address - Country:US
Mailing Address - Phone:262-339-5268
Mailing Address - Fax:
Practice Address - Street 1:2416 SPRINGDALE RD APT 205
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-2738
Practice Address - Country:US
Practice Address - Phone:262-339-5268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI5508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program