Provider Demographics
NPI:1831130996
Name:KELLEY, MARK DONALD (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DONALD
Last Name:KELLEY
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:DONALD
Other - Last Name:RALPH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:2537 MOMENTUM PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-0001
Mailing Address - Country:US
Mailing Address - Phone:616-975-1845
Mailing Address - Fax:616-975-1870
Practice Address - Street 1:100 MICHIGAN ST NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2560
Practice Address - Country:US
Practice Address - Phone:616-391-1680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704173671363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00725240OtherRAILROAD MEDICARE
MIN30190011Medicare PIN
MIQ70152Medicare UPIN