1982146213 NPI number — MRS. KATHRYN DIANE TAILLIE PA-C

Table of content: MRS. KATHRYN DIANE TAILLIE PA-C (NPI 1982146213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982146213 NPI number — MRS. KATHRYN DIANE TAILLIE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAILLIE
Provider First Name:
KATHRYN
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEMPSEY
Provider Other First Name:
KATHRYN
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1982146213
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10001 W INNOVATION DR STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-4851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-771-6780
Provider Business Mailing Address Fax Number:
414-238-2424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2885 N MAYFAIR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUWATCSA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53222-4404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-771-6780
Provider Business Practice Location Address Fax Number:
414-238-2424
Provider Enumeration Date:
11/17/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  085.006036 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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