Provider Demographics
NPI:1447878731
Name:LENZ, KYLIE (PAC)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:LENZ
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:
Other - Last Name:NELSEN-FREUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1155 N MAYFAIR RD FL 3
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3464
Mailing Address - Country:US
Mailing Address - Phone:414-955-5990
Mailing Address - Fax:414-955-6282
Practice Address - Street 1:1155 N MAYFAIR RD FL 3
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3464
Practice Address - Country:US
Practice Address - Phone:414-955-5990
Practice Address - Fax:414-955-6282
Is Sole Proprietor?:No
Enumeration Date:2020-07-13
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1447878731Medicaid