Provider Demographics
NPI:1346413309
Name:YOUNG, KELLEY MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:MARIE
Last Name:YOUNG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12520 CROCKERY CREEK DRIVE
Mailing Address - Street 2:P.O. BOX 179
Mailing Address - City:RAVENNA
Mailing Address - State:MI
Mailing Address - Zip Code:49451-0179
Mailing Address - Country:US
Mailing Address - Phone:231-853-2954
Mailing Address - Fax:231-853-6089
Practice Address - Street 1:12520 CROCKERY CREEK DRIVE
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:MI
Practice Address - Zip Code:49451
Practice Address - Country:US
Practice Address - Phone:231-853-2954
Practice Address - Fax:231-853-6089
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704210304363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N86490Medicare PIN