Provider Demographics
NPI:1821232455
Name:WATERS, KELLY ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANNE
Last Name:WATERS
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC 845
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 1:4100 LAKE DR SE STE 200
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-8292
Practice Address - Country:US
Practice Address - Phone:616-391-3759
Practice Address - Fax:616-391-3052
Is Sole Proprietor?:No
Enumeration Date:2009-04-27
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301104008207RS0012X, 2084S0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine