Provider Demographics
NPI:1689259467
Name:NICELY, KRISTEN M
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:M
Last Name:NICELY
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 1:330 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:VA
Mailing Address - Zip Code:24416-2712
Mailing Address - Country:US
Mailing Address - Phone:540-461-1549
Mailing Address - Fax:
Practice Address - Street 1:330 E 20TH ST
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:VA
Practice Address - Zip Code:24416-2712
Practice Address - Country:US
Practice Address - Phone:540-461-1549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-13
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver