1568916930 NPI number — MS. KELLY ANN STETSER MS, AT, ATC, CEIS

Table of content: MS. KELLY ANN STETSER MS, AT, ATC, CEIS (NPI 1568916930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568916930 NPI number — MS. KELLY ANN STETSER MS, AT, ATC, CEIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STETSER
Provider First Name:
KELLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, AT, ATC, CEIS
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:
1568916930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4182 PINE CREEK RD SW
Provider Second Line Business Mailing Address:
APT 4
Provider Business Mailing Address City Name:
GRANDVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49418-2528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-217-4565
Provider Business Mailing Address Fax Number:
616-748-7033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
725 E MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ZEELAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49464-1331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-748-7234
Provider Business Practice Location Address Fax Number:
616-748-7033
Provider Enumeration Date:
08/15/2016

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: 252Y00000X , with the licence number:  S332465067653 , 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)





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