Basic Information
| Provider Information | |||||||||
| NPI: | 1720637176 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KENNY | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | CAROLYNN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 342 N WATER ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532025715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513421039 | ||||||||
| FaxNumber: | 6513421428 | ||||||||
| Practice Location | |||||||||
| Address1: | 342 N WATER ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532025715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513421039 | ||||||||
| FaxNumber: | 6513421428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2019 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 5737-23 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.