Provider Demographics
NPI:1962034850
Name:DEWENT, KELLY ELLEN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELLEN
Last Name:DEWENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7652 FINCH AVE
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-9147
Mailing Address - Country:US
Mailing Address - Phone:616-690-4107
Mailing Address - Fax:
Practice Address - Street 1:3097 PRAIRIE ST SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2000
Practice Address - Country:US
Practice Address - Phone:616-531-9973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704154590163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse