Provider Demographics
NPI:1093474421
Name:ICKES, KRISTEN MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:MICHELLE
Last Name:ICKES
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 1:2708 COUNTY ROAD 62
Mailing Address - Street 2:
Mailing Address - City:GIBSONBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43431-9579
Mailing Address - Country:US
Mailing Address - Phone:567-201-5573
Mailing Address - Fax:
Practice Address - Street 1:3265 US HIGHWAY 20 W
Practice Address - Street 2:
Practice Address - City:LINDSEY
Practice Address - State:OH
Practice Address - Zip Code:43442-9712
Practice Address - Country:US
Practice Address - Phone:567-201-5573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant