Healthcare Provider Details

I. General information

NPI: 1316757271
Provider Name (Legal Business Name): KRISTIN MICELI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 01/13/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4665 BELPAR ST NW
CANTON OH
44718-3602
US

IV. Provider business mailing address

4665 BELPAR ST NW
CANTON OH
44718-3602
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-1480
  • Fax:
Mailing address:
  • Phone: 330-493-1480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.0038280
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: