Provider Demographics
NPI:1972724821
Name:KELLEY, BETH A (NP, CNM)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:A
Last Name:KELLEY
Suffix:
Gender:F
Credentials:NP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 E CHICAGO RD
Mailing Address - Street 2:
Mailing Address - City:STURGIS
Mailing Address - State:MI
Mailing Address - Zip Code:49091-8524
Mailing Address - Country:US
Mailing Address - Phone:269-659-6747
Mailing Address - Fax:269-659-6746
Practice Address - Street 1:1717 E. CHICAGO ROAD
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-2372
Practice Address - Country:US
Practice Address - Phone:269-659-6747
Practice Address - Fax:269-659-6746
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704194227363L00000X, 363LF0000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000612032OtherBCBS
IN200932840Medicaid
MI160G510560OtherBCBS GROUP-WOMENS SERVICES
MI700G560080OtherBCBS GROUP-THREE RIVERS HEALTH