Provider Demographics
NPI:1871739995
Name:BEAHM, MICHELLE KRISTIE (NP)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:KRISTIE
Last Name:BEAHM
Suffix:
Gender:
Credentials:NP
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:KRISTIE
Other - Last Name:KONKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:5555 N PORT WASHINGTON RD STE 200
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4927
Mailing Address - Country:US
Mailing Address - Phone:262-999-3495
Mailing Address - Fax:
Practice Address - Street 1:5555 N PORT WASHINGTON RD STE 200
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-4927
Practice Address - Country:US
Practice Address - Phone:262-999-3495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI161780-030163W00000X
WI15751363L00000X
WI15751-33363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1871739995Medicaid