Provider Demographics
NPI:1023869138
Name:KELLY, ANGELA JUDITH (LMT)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:JUDITH
Last Name:KELLY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7438 M 68
Mailing Address - Street 2:
Mailing Address - City:ROGERS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49779-9735
Mailing Address - Country:US
Mailing Address - Phone:989-306-1864
Mailing Address - Fax:
Practice Address - Street 1:784 N BRADLEY HWY
Practice Address - Street 2:
Practice Address - City:ROGERS CITY
Practice Address - State:MI
Practice Address - Zip Code:49779-1513
Practice Address - Country:US
Practice Address - Phone:989-734-7144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501004508225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist