Provider Demographics
NPI:1619548740
Name:FOBBE, KELSEY (RN)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:FOBBE
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 1:2063 SECRETARIAT LN
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-8034
Mailing Address - Country:US
Mailing Address - Phone:517-282-1295
Mailing Address - Fax:
Practice Address - Street 1:2063 SECRETARIAT LN
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-8034
Practice Address - Country:US
Practice Address - Phone:517-282-1295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704278919163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse