Provider Demographics
NPI:1689790941
Name:KELLY, SHANTEL MARGRIE (MT)
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:MARGRIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7971 BOLT DR SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9391
Mailing Address - Country:US
Mailing Address - Phone:616-209-2082
Mailing Address - Fax:
Practice Address - Street 1:7971 BOLT DR SE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-9391
Practice Address - Country:US
Practice Address - Phone:616-209-2082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist