Provider Demographics
NPI:1720580277
Name:NIEMAN, KELLY (ARNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:NIEMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S ILLINOIS AVE SUITE 103
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5489
Mailing Address - Country:US
Mailing Address - Phone:641-428-3041
Mailing Address - Fax:641-428-3059
Practice Address - Street 1:401 SOUTH 15TH STREET
Practice Address - Street 2:
Practice Address - City:CLEAR LAKE
Practice Address - State:IA
Practice Address - Zip Code:50428
Practice Address - Country:US
Practice Address - Phone:641-357-7442
Practice Address - Fax:641-357-3070
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA136011363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily