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NPI Code Detail

MEDICARE: NICOLE KELLY

MEDICARE: NICOLE KELLY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225200000XPhysical Therapy Assistant2340-19WI
2225200000XPhysical Therapy AssistantA1718MN

General Provider Information

NPI Number : 1336523562
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICOLE KELLY
Provider Business Mailing Address
First Line : 4038 MUNGER SHAW RD
Second Line :
City : CLOQUET
State : MN
Zip : 55720-9255
Country : US
Telephone Number : 218-590-9285
Fax Number :
Provider Business Practice Location Address
First Line : 35 N 28TH ST
Second Line :
City : SUPERIOR
State : WI
Zip : 54880-5557
Country : US
Telephone Number : 715-392-3300
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/17/2015
Last Update Date : 07/17/2015

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Directions to “ NICOLE KELLY ” Practice Location

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