Provider Demographics
NPI:1710593645
Name:KIDD, KASEY NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:NICOLE
Last Name:KIDD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2340 W SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-4108
Mailing Address - Country:US
Mailing Address - Phone:765-452-4437
Mailing Address - Fax:
Practice Address - Street 1:2340 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-4108
Practice Address - Country:US
Practice Address - Phone:654-524-4377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28222341A363LF0000X
IN71010411A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily