Provider Demographics
NPI:1043339468
Name:KELLUM, NICOLE RENEE (ND)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:RENEE
Last Name:KELLUM
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10435 N SCOTTSDALE RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-4530
Mailing Address - Country:US
Mailing Address - Phone:603-660-8972
Mailing Address - Fax:
Practice Address - Street 1:531 E LYNWOOD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1626
Practice Address - Country:US
Practice Address - Phone:603-660-8972
Practice Address - Fax:602-626-3555
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ09-1131175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath