Provider Demographics
NPI:1457962037
Name:PROVENCHER, NATALIE KIEL
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:KIEL
Last Name:PROVENCHER
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 1:2800 S HIGHLAND MESA RD APT 2-108
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-7173
Mailing Address - Country:US
Mailing Address - Phone:520-342-8264
Mailing Address - Fax:
Practice Address - Street 1:2800 S HIGHLAND MESA RD APT 2-108
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7173
Practice Address - Country:US
Practice Address - Phone:520-342-8264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program