Provider Demographics
NPI:1215563747
Name:ZDAN, KELLY-RAE AMBER
Entity Type:Individual
Prefix:MISS
First Name:KELLY-RAE
Middle Name:AMBER
Last Name:ZDAN
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 1:940 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-2546
Mailing Address - Country:US
Mailing Address - Phone:431-233-3655
Mailing Address - Fax:
Practice Address - Street 1:940 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2546
Practice Address - Country:US
Practice Address - Phone:431-233-3655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer