Healthcare Provider Details

I. General information

NPI: 1396539789
Provider Name (Legal Business Name): KAELLI NIKELLE THIEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 04/08/2025
Certification Date: 04/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 N 11TH ST
RICHMOND VA
23298-5024
US

IV. Provider business mailing address

1200 E BROAD ST # 980257
RICHMOND VA
23298-5025
US

V. Phone/Fax

Practice location:
  • Phone: 804-827-1204
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: