Provider Demographics
NPI:1790765139
Name:LEE, KYOUNG KELLY (NP)
Entity Type:Individual
Prefix:MS
First Name:KYOUNG
Middle Name:KELLY
Last Name:LEE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KYOUNG-EUN
Other - Middle Name:KELLY
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 42
Mailing Address - Street 2:601 JOHN STREET
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:3300 WEST CENTRE AVE
Practice Address - Street 2:BRONSON OB/GYN ASSOCIATES
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-327-2211
Practice Address - Fax:269-327-0273
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704247830363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4770217Medicaid
MI4770217Medicaid