Provider Demographics
NPI:1447320403
Name:WELLS-HOLTEY, HEATHER MARIE (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:MARIE
Last Name:WELLS-HOLTEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:MARIE
Other - Last Name:WELLS-HOLTEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:788 N JEFFERSON ST
Mailing Address - Street 2:SUITE 300 /ATTN KAAREN BUTZEN
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3718
Mailing Address - Country:US
Mailing Address - Phone:414-227-8950
Mailing Address - Fax:414-272-0859
Practice Address - Street 1:2350 N. LAKE DRIVE
Practice Address - Street 2:SUITE 300
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4528
Practice Address - Country:US
Practice Address - Phone:414-298-7100
Practice Address - Fax:414-298-7101
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41524207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1447320403Medicaid
WI003873645Medicare PIN