Provider Demographics
NPI:1215568548
Name:MANN, KELLY (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MANN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2155 E PARIS AVE SE STE 210
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-6195
Mailing Address - Country:US
Mailing Address - Phone:616-655-1570
Mailing Address - Fax:616-655-1571
Practice Address - Street 1:2155 E PARIS AVE SE STE 210
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6195
Practice Address - Country:US
Practice Address - Phone:616-655-1570
Practice Address - Fax:616-655-1571
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant