Healthcare Provider Details

I. General information

NPI: 1073881629
Provider Name (Legal Business Name): KELLY MARIE MATHISON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2011
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 N MCEWAN ST
CLARE MI
48617-1440
US

IV. Provider business mailing address

703 N MCEWAN ST
CLARE MI
48617-1440
US

V. Phone/Fax

Practice location:
  • Phone: 898-802-5000
  • Fax:
Mailing address:
  • Phone: 586-322-9126
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704254007
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704254007
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: