MEDICARE: NICOLE L KEMP PTA

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
1	225200000X	Physical Therapy Assistant	69-019	WI

General Provider Information

NPI Number	:	1740488188
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE L KEMP PTA

Provider Business Mailing Address
First Line	:	6820 WOODLAND BLVD
Second Line	:
City	:	MINNESOTA CITY
State	:	MN
Zip	:	55959-1204
Country	:	US
Telephone Number	:	507-474-3202
Fax Number	:	507-452-5735

Provider Business Practice Location Address
First Line	:	270 N ST.
Second Line	:
City	:	FOUNTAIN CITY
State	:	WI
Zip	:	54629
Country	:	US
Telephone Number	:	608-687-7721
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2007
Last Update Date	:	07/08/2007

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