Provider Demographics
NPI:1891755104
Name:VERELLEN, KIMBERLY L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:L
Last Name:VERELLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 SCHOOL HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:IMLAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48444-1242
Mailing Address - Country:US
Mailing Address - Phone:810-724-4021
Mailing Address - Fax:
Practice Address - Street 1:4472 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROWN CITY
Practice Address - State:MI
Practice Address - Zip Code:48416-7908
Practice Address - Country:US
Practice Address - Phone:810-346-2751
Practice Address - Fax:810-346-3238
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIG66499P03Medicare ID - Type UnspecifiedMEDICARE PART B
MI238577Medicare Oscar/Certification
MIP16043Medicare UPIN