Provider Demographics
NPI:1942270004
Name:NICKELL, KENT A (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:A
Last Name:NICKELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2400 N ROCKTON AVE
Mailing Address - Street 2:MERCYHEALTH- ROCKFORD HEALTH PHYSICIANS
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61103-3655
Mailing Address - Country:US
Mailing Address - Phone:815-971-5000
Mailing Address - Fax:
Practice Address - Street 1:1825 LOGAN AVE
Practice Address - Street 2:NORTHEAST IOWA PATHOLOGY ASSOCIATES,PC
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1916
Practice Address - Country:US
Practice Address - Phone:319-235-3679
Practice Address - Fax:319-233-0722
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA32811207ZP0101X
IL036148445207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology