Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 16033 | WI |
NPI | 1003802331 |
---|---|
Provider Name | Mary R Kelm |
First Address | Fond Du Lac, WI 54935-4560 |
Second Address | Fond Du Lac, WI 54935-4560 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/09/2005 |
Last Update Date | 28/03/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P02949 | (02) |