Provider Demographics
NPI:1265268841
Name:IVESON-COOLEY, KELLY LYNN (CHW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:IVESON-COOLEY
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 S BUNN RD
Mailing Address - Street 2:
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-6300
Mailing Address - Country:US
Mailing Address - Phone:517-439-5584
Mailing Address - Fax:517-592-1975
Practice Address - Street 1:1331 S BUNN RD
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-6300
Practice Address - Country:US
Practice Address - Phone:517-439-5584
Practice Address - Fax:517-592-1975
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker