Provider Demographics
NPI:1750638458
Name:KELLEY, LYNN MARIE (RN)
Entity Type:Individual
Prefix:MS
First Name:LYNN
Middle Name:MARIE
Last Name:KELLEY
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 1:1471 GRACE ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-1678
Mailing Address - Country:US
Mailing Address - Phone:616-913-2006
Mailing Address - Fax:616-913-2005
Practice Address - Street 1:1471 GRACE ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-1678
Practice Address - Country:US
Practice Address - Phone:616-913-2006
Practice Address - Fax:616-913-2005
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704146281163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse