Provider Demographics
NPI:1750835005
Name:LEVITT, KELLY ANN (CNM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:LEVITT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:RISICATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 68TH ST SE STE 301
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-6980
Practice Address - Country:US
Practice Address - Phone:616-391-3302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704335550367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife