Healthcare Provider Details

I. General information

NPI: 1386388809
Provider Name (Legal Business Name): KELLY RAE VOGEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NAVARRE PLACE SUITE 4470
SOUTH BEND IN
46601
US

IV. Provider business mailing address

1140 QUIGLEY PL
SOUTH BEND IN
46617-4406
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1405
  • Fax: 574-647-3970
Mailing address:
  • Phone: 519-067-8919
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number28239544A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number71016343A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: