Provider Demographics
NPI:1043060130
Name:GAVINSKI, KELLIE LOUISE
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:LOUISE
Last Name:GAVINSKI
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 1:3921 MIRAMAR AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-2456
Mailing Address - Country:US
Mailing Address - Phone:616-322-4031
Mailing Address - Fax:
Practice Address - Street 1:3921 MIRAMAR AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-2456
Practice Address - Country:US
Practice Address - Phone:616-322-4031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide