Basic Information
| Provider Information | |||||||||
| NPI: | 1821090440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAMELLE | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 W KK RIVER PARKWAY | ||||||||
| Address2: | SUITE 245 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146496780 | ||||||||
| FaxNumber: | 4146496030 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 W KK RIVER PARKWAY | ||||||||
| Address2: | SUITE 245 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4146496780 | ||||||||
| FaxNumber: | 4146496030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2252 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1821090440 | 05 | WI | MEDICAID | 739750881 | 01 | WI | MEDICARE PROVIDER | OTHER |