Provider Demographics
NPI:1912405820
Name:RICKEY, KELSIE MAKENNA LANG
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:MAKENNA LANG
Last Name:RICKEY
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 1:5529 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35222-4140
Mailing Address - Country:US
Mailing Address - Phone:256-606-8453
Mailing Address - Fax:
Practice Address - Street 1:2409 ACTON RD STE 153
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35243-2939
Practice Address - Country:US
Practice Address - Phone:205-379-0174
Practice Address - Fax:888-219-8102
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-146246363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily