Provider Demographics
NPI:1710485669
Name:WEISS, KELLY JOANNE (RN)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JOANNE
Last Name:WEISS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:JOANNE
Other - Last Name:MUNGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN & LPN
Mailing Address - Street 1:1447 N. HARRISON
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602
Mailing Address - Country:US
Mailing Address - Phone:989-583-5153
Mailing Address - Fax:989-583-5226
Practice Address - Street 1:5400 MACKINAW
Practice Address - Street 2:SUITE 1400
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604
Practice Address - Country:US
Practice Address - Phone:989-583-5193
Practice Address - Fax:989-583-5226
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704191818-RN163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator