Provider Demographics
NPI:1386008787
Name:ICEMAN, KELLI (DPM)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:
Last Name:ICEMAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8805 PINE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-7064
Mailing Address - Country:US
Mailing Address - Phone:231-779-3668
Mailing Address - Fax:
Practice Address - Street 1:8805 PINE RIDGE DR
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-7064
Practice Address - Country:US
Practice Address - Phone:231-779-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1137213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist