Healthcare Provider Details

I. General information

NPI: 1831130996
Provider Name (Legal Business Name): MARK DONALD KELLEY FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MARK DONALD RALPH NP-C

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

2537 MOMENTUM PL
CHICAGO IL
60689-0001
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-1680
  • Fax:
Mailing address:
  • Phone: 616-975-1845
  • Fax: 616-975-1870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704173671
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: