Healthcare Provider Details

I. General information

NPI: 1528850674
Provider Name (Legal Business Name): KELLY NICOLE URBANIAK L/PTA, CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2025
Last Update Date: 05/22/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 E 16TH ST
HOLLAND MI
49423-9127
US

IV. Provider business mailing address

1221 E 16TH ST
HOLLAND MI
49423-9127
US

V. Phone/Fax

Practice location:
  • Phone: 616-396-7095
  • Fax:
Mailing address:
  • Phone: 616-396-7095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number5502002157
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: