Kelsey Clark
Individual provider Active NPI Pharmacist · Whitewater, WI
NPI 1972102465 · NPPES record last updated Oct 26, 2020
Key facts
- NPI
- 1972102465
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pharmacist 183500000X
- License
- 17484 (WI)
- Practice address
- 1362 W Main St
Whitewater, WI 53190-1504 - Phone
- (262) 473-7740
- NPI assigned
- Oct 26, 2020
- Sex
- Female
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 17484 | WI | MD | Pharmacist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 17484 | WI | Yes |
Addresses
Primary practice location
1362 W Main St
Whitewater, WI 53190-1504
Mailing address
1362 W Main St
Whitewater, WI 53190-1504
Phone (262) 473-7740
Other providers in Whitewater, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 26, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.