Provider Demographics
NPI:1447590641
Name:KEMP, NICOLE D (APRN)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:D
Last Name:KEMP
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:D
Other - Last Name:EMERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C, IBCLC-C
Mailing Address - Street 1:PO BOX 13442
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24034-3442
Mailing Address - Country:US
Mailing Address - Phone:785-554-3016
Mailing Address - Fax:
Practice Address - Street 1:325 MOUNTAIN AVENUE SW
Practice Address - Street 2:STE 2
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4044
Practice Address - Country:US
Practice Address - Phone:540-580-0310
Practice Address - Fax:945-202-3627
Is Sole Proprietor?:No
Enumeration Date:2013-02-25
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-75815-061363L00000X
MDAC003118363L00000X
PA740164363LF0000X
TX1049941363LF0000X
VA0024170871363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS068002213OtherMEDICARE PTAN
KS201007510AMedicaid