Provider Demographics
NPI:1679354104
Name:ENNEN, KALA RAE ANN
Entity type:Individual
Prefix:
First Name:KALA
Middle Name:RAE ANN
Last Name:ENNEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KALA
Other - Middle Name:RAE ANN
Other - Last Name:INGWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 860912
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486-0912
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:1400 BELLINGER ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54703-9943
Practice Address - Country:US
Practice Address - Phone:715-838-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-10
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17098-33367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered