Provider Demographics
NPI:1679852081
Name:NICKERSON, KYLEE RAI
Entity Type:Individual
Prefix:MRS
First Name:KYLEE
Middle Name:RAI
Last Name:NICKERSON
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 1:21408 E CREOSOTE LN
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-9330
Mailing Address - Country:US
Mailing Address - Phone:480-703-5311
Mailing Address - Fax:
Practice Address - Street 1:21408 EAST CREOSOTE LANE
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142
Practice Address - Country:US
Practice Address - Phone:480-703-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA73692355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant