Individual
KELLY FLACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
APNP
Contact information
Practice address
855 N WESTHAVEN DR, OSHKOSH, WI 54904-7668
(920) 033-8700
(920) 456-5901
Mailing address
855 N WESTHAVEN DR, OSHKOSH, WI 54904-7668
(920) 033-8700
(920) 456-5901
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
177650-30
WI
363L00000X
Nurse Practitioner
Primary
10176-33
WI
363LF0000X
Family Nurse Practitioner
10176-33
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100146891
—
WI
01
—
10176-33
WISCONSIN APNP LICENSE
WI
01
—
177650-30
WISCONSIN RN LICENSE
WI
Enumeration date
05/19/2020
Last updated
11/18/2021
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