Provider Demographics
NPI:1053700682
Name:FREE, DOROTHY KATHERINE
Entity type:Individual
Prefix:
First Name:DOROTHY
Middle Name:KATHERINE
Last Name:FREE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 75TH ST
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-8323
Mailing Address - Country:US
Mailing Address - Phone:262-948-5600
Mailing Address - Fax:262-948-5735
Practice Address - Street 1:10400 75TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8323
Practice Address - Country:US
Practice Address - Phone:262-948-5600
Practice Address - Fax:262-948-5735
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127249367500000X
WI7903-033367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100072228Medicaid