Provider Demographics
NPI:1861977084
Name:NIESE, KELLIE JO (RN)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:JO
Last Name:NIESE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:JO
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1040 S WINTER ST STE 1022
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-3867
Mailing Address - Country:US
Mailing Address - Phone:517-263-8905
Mailing Address - Fax:517-263-7616
Practice Address - Street 1:1040 S WINTER ST STE 1022
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-3867
Practice Address - Country:US
Practice Address - Phone:517-263-8905
Practice Address - Fax:517-263-7616
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704250179163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health