Healthcare Provider Details

I. General information

NPI: 1568051068
Provider Name (Legal Business Name): NOELLE KAMINSKI MAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 PAGE AVE
JACKSON MI
49201-2418
US

IV. Provider business mailing address

1218 RUNAWAY BAY DR APT 3B
LANSING MI
48917-8749
US

V. Phone/Fax

Practice location:
  • Phone: 517-783-6670
  • Fax:
Mailing address:
  • Phone: 586-907-8144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: