Provider Demographics
NPI:1972963692
Name:WANLESS, KETURA (RN, PHN)
Entity type:Individual
Prefix:
First Name:KETURA
Middle Name:
Last Name:WANLESS
Suffix:
Gender:F
Credentials:RN, PHN
Other - Prefix:
Other - First Name:KETURA
Other - Middle Name:
Other - Last Name:WANLESS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, PHN
Mailing Address - Street 1:514 RIVERVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3631
Mailing Address - Country:US
Mailing Address - Phone:262-548-8472
Mailing Address - Fax:
Practice Address - Street 1:514 RIVERVIEW AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3631
Practice Address - Country:US
Practice Address - Phone:262-548-8472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI222215-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse