Basic Information
| Provider Information | |||||||||
| NPI: | 1063433316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KALK | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | LORRAINE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 620 SMITH AVE | ||||||||
| Address2: | |||||||||
| City: | OCONTO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541531080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208344110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 940 S SAINT AUGUSTINE ST | ||||||||
| Address2: | |||||||||
| City: | PULASKI | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541629453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9204964700 | ||||||||
| FaxNumber: | 9204964705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2006 | ||||||||
| LastUpdateDate: | 12/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1034 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 42985400 | 05 | WI | MEDICAID |