Healthcare Provider Details

I. General information

NPI: 1174382238
Provider Name (Legal Business Name): KAILEY NOBLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 W DELAWARE ST
DECATUR MI
49045-1106
US

IV. Provider business mailing address

319 W DELAWARE ST
DECATUR MI
49045-1106
US

V. Phone/Fax

Practice location:
  • Phone: 269-423-7028
  • Fax: 269-423-8282
Mailing address:
  • Phone: 269-423-7028
  • Fax: 269-423-8282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number4704285266
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: