Healthcare Provider Details

I. General information

NPI: 1740488188
Provider Name (Legal Business Name): NICOLE L KEMP PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 N ST.
FOUNTAIN CITY WI
54629
US

IV. Provider business mailing address

6820 WOODLAND BLVD
MINNESOTA CITY MN
55959-1204
US

V. Phone/Fax

Practice location:
  • Phone: 608-687-7721
  • Fax:
Mailing address:
  • Phone: 507-474-3202
  • Fax: 507-452-5735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number69-019
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: