=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265241764
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY MARIE ERICKSEN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2024
-----------------------------------------------------
Last Update Date | 12/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 403 3RD ST
-----------------------------------------------------
City | YUTAN
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68073-3143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-957-0703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9815 MADISON PLZ APT 10
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68127-3262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-957-0703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------