Provider Demographics
NPI:1164552303
Name:KIRKSEY, NICOLE DAYNA
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:DAYNA
Last Name:KIRKSEY
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 1:1442 STRUBLE AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-1253
Mailing Address - Country:US
Mailing Address - Phone:330-455-2739
Mailing Address - Fax:
Practice Address - Street 1:1442 STRUBLE AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-1253
Practice Address - Country:US
Practice Address - Phone:330-830-6317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRV046173172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2509413Medicaid