Provider Demographics
NPI:1487969291
Name:KELLY, WENDY CARROLL
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:CARROLL
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1737 PATRIOT WAY
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-2730
Mailing Address - Country:US
Mailing Address - Phone:262-884-7137
Mailing Address - Fax:
Practice Address - Street 1:1320 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53403-1978
Practice Address - Country:US
Practice Address - Phone:262-687-2699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program