Provider Demographics
NPI:1275283194
Name:NICELY, TIALA SHAINA KAWELA (BA)
Entity Type:Individual
Prefix:
First Name:TIALA
Middle Name:SHAINA KAWELA
Last Name:NICELY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 KESSEL CT STE 105
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-6227
Mailing Address - Country:US
Mailing Address - Phone:608-280-2700
Mailing Address - Fax:
Practice Address - Street 1:1440 E WISCONSIN ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-2552
Practice Address - Country:US
Practice Address - Phone:608-745-9720
Practice Address - Fax:608-745-9721
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator