Provider Demographics
NPI:1417979956
Name:BARTLEY, KERRY L (NP)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:L
Last Name:BARTLEY
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 1:1500 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827-1952
Mailing Address - Country:US
Mailing Address - Phone:517-663-2671
Mailing Address - Fax:517-999-4510
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EATON RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:48827-1952
Practice Address - Country:US
Practice Address - Phone:517-663-2671
Practice Address - Fax:517-999-4510
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKB141788363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417979956Medicaid
MI1417979956Medicaid