Provider Demographics
NPI:1861975476
Name:SCHULTZ, KELLY (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SCHULTZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:VIGANSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 40412
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-1255
Mailing Address - Country:US
Mailing Address - Phone:248-824-6500
Mailing Address - Fax:855-618-6655
Practice Address - Street 1:2725 AIRVIEW BLVD STE 105
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1804
Practice Address - Country:US
Practice Address - Phone:269-349-8386
Practice Address - Fax:269-349-8397
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2025-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008809363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant