Provider Demographics
NPI:1841032893
Name:KIES, CASEY LYNE (CHW)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:LYNE
Last Name:KIES
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 1:10767 E TRAVERSE HWY
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-6219
Mailing Address - Country:US
Mailing Address - Phone:231-947-1112
Mailing Address - Fax:
Practice Address - Street 1:10767 E TRAVERSE HWY
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-6219
Practice Address - Country:US
Practice Address - Phone:231-720-9147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker