Provider Demographics
NPI:1164734984
Name:KELLOGG, TRESSA (NP)
Entity Type:Individual
Prefix:
First Name:TRESSA
Middle Name:
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 S SULLIVAN AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-1548
Mailing Address - Country:US
Mailing Address - Phone:231-924-3300
Mailing Address - Fax:
Practice Address - Street 1:212 S SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1548
Practice Address - Country:US
Practice Address - Phone:231-924-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47204186363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI47204186OtherSTATE LICENSE