Provider Demographics
NPI:1295805851
Name:LE BEL, KRISTIN LYNN (PA)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:LYNN
Last Name:LE BEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:LYNN
Other - Last Name:KING-SHANK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 W OAK ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1526
Practice Address - Country:US
Practice Address - Phone:231-924-6095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003953363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P93621Medicare UPIN
0P01500Medicare ID - Type Unspecified