Provider Demographics
NPI:1629141999
Name:EVERDEN, KELLY (CPNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:EVERDEN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 N SAGINAW ST
Mailing Address - Street 2:OAKLAND PRIMARY HEALTH SERVICES
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2155
Mailing Address - Country:US
Mailing Address - Phone:248-322-6747
Mailing Address - Fax:248-322-5787
Practice Address - Street 1:1051 ARLENE AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-2904
Practice Address - Country:US
Practice Address - Phone:248-451-7365
Practice Address - Fax:248-451-7370
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704213499363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics