Provider Demographics
NPI:1073900387
Name:CHRISTOPHEL, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CHRISTOPHEL
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 1:4024 20 MILE RD
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:MI
Mailing Address - Zip Code:49245-9615
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:879 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-2045
Practice Address - Country:US
Practice Address - Phone:269-781-4251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-24
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006633174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist