Provider Demographics
NPI:1730411497
Name:JERDET ENGEN, KELLI MARIE (RN, BSN)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:MARIE
Last Name:JERDET ENGEN
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N6520 GUY ROAD
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-1741
Mailing Address - Country:US
Mailing Address - Phone:715-284-9851
Mailing Address - Fax:715-284-5150
Practice Address - Street 1:N6520 GUY ROAD
Practice Address - Street 2:HO-CHUNK HEALTH CARE CENTER
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-1741
Practice Address - Country:US
Practice Address - Phone:715-284-9851
Practice Address - Fax:715-284-5150
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI160751-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse