1285714725 NPI number — MRS. KELLY LYNN BRIZENDINE PAC

Table of content: MRS. KELLY LYNN BRIZENDINE PAC (NPI 1285714725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285714725 NPI number — MRS. KELLY LYNN BRIZENDINE PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRIZENDINE
Provider First Name:
KELLY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285714725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2845 CAPITAL AVE SW
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
BATTLE CREEK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49015-4185
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-969-6177
Provider Business Mailing Address Fax Number:
269-969-8776

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2845 CAPITAL AVE SW
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
BATTLE CREEK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49015-4185
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-969-6177
Provider Business Practice Location Address Fax Number:
269-969-8776
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  5601004377 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 5601004377 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com