Provider Demographics
NPI:1588184436
Name:DONASTORG, KELLIE RENEE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:RENEE
Last Name:DONASTORG
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 HUNTERS RUN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-6301
Mailing Address - Country:US
Mailing Address - Phone:810-656-3004
Mailing Address - Fax:
Practice Address - Street 1:1113 HUNTERS RUN DR
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-6301
Practice Address - Country:US
Practice Address - Phone:810-656-3004
Practice Address - Fax:810-656-3004
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2017-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704230071363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily