Healthcare Provider Details

I. General information

NPI: 1952125544
Provider Name (Legal Business Name): KENNEDY NICOLE CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2024
Last Update Date: 11/11/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5905 O ST
LINCOLN NE
68510-2235
US

IV. Provider business mailing address

5905 O ST
LINCOLN NE
68510-2235
US

V. Phone/Fax

Practice location:
  • Phone: 402-436-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: