Provider Demographics
NPI:1831133016
Name:COLEMAN, KELLY M (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1848
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49443-1848
Mailing Address - Country:US
Mailing Address - Phone:231-727-4444
Mailing Address - Fax:231-727-4451
Practice Address - Street 1:3535 PARK ST
Practice Address - Street 2:#110
Practice Address - City:NORTON SHORES
Practice Address - State:MI
Practice Address - Zip Code:49444-3736
Practice Address - Country:US
Practice Address - Phone:231-739-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704243275363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4837100Medicaid
MIS99399Medicare UPIN