Healthcare Provider Details

I. General information

NPI: 1184487753
Provider Name (Legal Business Name): KELLEY A NICKEL CPRM CPS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLEY A. MARSHMAN

II. Dates (important events)

Enumeration Date: 02/05/2024
Last Update Date: 02/05/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 M 60 E
CASSOPOLIS MI
49031-9339
US

IV. Provider business mailing address

960 M 60 E
CASSOPOLIS MI
49031-9339
US

V. Phone/Fax

Practice location:
  • Phone: 269-445-2451
  • Fax: 269-445-3836
Mailing address:
  • Phone: 269-445-2451
  • Fax: 269-445-3836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: