Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0208X | Pediatric Infectious Diseases | 31214 | WI |
NPI | 1033161708 |
---|---|
Provider Name | Dr. Kelly Henrickson |
First Address | Milwaukee, WI 53226-4874 |
Second Address | Milwaukee, WI 53226-4874 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2006 |
Last Update Date | 26/02/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
002000198G | HUMANA (01) | |
1033161708 | (05) | WI |
E46207 | (02) |