Provider Demographics
NPI:1598305310
Name:BLYSTONE, KELSEY (RN)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:BLYSTONE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 BAYBERRY POINTE DR NW APT F
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-4611
Mailing Address - Country:US
Mailing Address - Phone:473-961-6644
Mailing Address - Fax:
Practice Address - Street 1:1853 R W BERENDS DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-4955
Practice Address - Country:US
Practice Address - Phone:616-534-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704323983163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse