Provider Demographics
NPI:1336523562
Name:KELLY, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4038 MUNGER SHAW RD
Mailing Address - Street 2:
Mailing Address - City:CLOQUET
Mailing Address - State:MN
Mailing Address - Zip Code:55720-9255
Mailing Address - Country:US
Mailing Address - Phone:218-590-9285
Mailing Address - Fax:
Practice Address - Street 1:35 N 28TH ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-5557
Practice Address - Country:US
Practice Address - Phone:715-392-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2340-19225200000X
MNA1718225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant