Provider Demographics
NPI:1952468530
Name:DALE, KELLY RENET (PA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RENET
Last Name:DALE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:2690 GERMANIA RD
Mailing Address - Street 2:
Mailing Address - City:MARLETTE
Mailing Address - State:MI
Mailing Address - Zip Code:48453-8965
Mailing Address - Country:US
Mailing Address - Phone:810-577-7395
Mailing Address - Fax:
Practice Address - Street 1:154 S MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:FRANKENMUTH
Practice Address - State:MI
Practice Address - Zip Code:48734-1692
Practice Address - Country:US
Practice Address - Phone:989-502-1122
Practice Address - Fax:989-502-1212
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601003127363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601003127OtherSTATE LICENSE NUMBER