Provider Demographics
NPI:1356718878
Name:SMALLEY, ELYSE
Entity type:Individual
Prefix:
First Name:ELYSE
Middle Name:
Last Name:SMALLEY
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 1:3169 THISTLE CT
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-9576
Mailing Address - Country:US
Mailing Address - Phone:734-834-7153
Mailing Address - Fax:
Practice Address - Street 1:222 FAIRBANKS AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3735
Practice Address - Country:US
Practice Address - Phone:616-395-7098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program