Provider Demographics
NPI:1407427990
Name:KELLY, ANNETTE LYN (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:LYN
Last Name:KELLY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4017 SNEAKY LN
Mailing Address - Street 2:
Mailing Address - City:HOLT
Mailing Address - State:MI
Mailing Address - Zip Code:48842-7759
Mailing Address - Country:US
Mailing Address - Phone:989-292-0390
Mailing Address - Fax:
Practice Address - Street 1:401 W GREENLAWN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2819
Practice Address - Country:US
Practice Address - Phone:517-975-6475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704235537363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health