Provider Demographics
NPI:1033706981
Name:REID, KELLY ELIZABETH (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:REID
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:LOOMIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:2177 TRAFALGER ST
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-1328
Mailing Address - Country:US
Mailing Address - Phone:616-745-0636
Mailing Address - Fax:
Practice Address - Street 1:702 W LAKE LANSING RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-8526
Practice Address - Country:US
Practice Address - Phone:517-332-5342
Practice Address - Fax:517-316-2893
Is Sole Proprietor?:No
Enumeration Date:2020-12-27
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704318260363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily