Healthcare Provider Details

I. General information

NPI: 1073387759
Provider Name (Legal Business Name): MRS. KELSEY ANN SPENCER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELSEY ANN JANTZ FNP-BC

II. Dates (important events)

Enumeration Date: 11/13/2023
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2861 COPPERGROVE DR NE
GRAND RAPIDS MI
49525-3170
US

IV. Provider business mailing address

11681 64TH AVE
ALLENDALE MI
49401-8477
US

V. Phone/Fax

Practice location:
  • Phone: 616-901-8564
  • Fax:
Mailing address:
  • Phone: 616-901-8564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704358989
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: