Provider Demographics
NPI:1811232879
Name:EGGIMAN, KELLY ELIZABETH
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:EGGIMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:O'BRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
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 1:100 MICHIGAN ST NE
Practice Address - Street 2:SUITE A721
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-3139
Practice Address - Fax:616-391-3044
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant