Provider Demographics
NPI:1437626942
Name:STAFFORD, KELLY J
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:STAFFORD
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 1:15126 160TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-8922
Mailing Address - Country:US
Mailing Address - Phone:616-638-3818
Mailing Address - Fax:
Practice Address - Street 1:1060 W NORTON AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-4175
Practice Address - Country:US
Practice Address - Phone:231-777-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist