Healthcare Provider Details

I. General information

NPI: 1710494042
Provider Name (Legal Business Name): SERENA LEIGH KELLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 DIAMOND AVE SE APT 1
GRAND RAPIDS MI
49506-1407
US

IV. Provider business mailing address

107 DIAMOND AVE SE APT 1
GRAND RAPIDS MI
49506-1407
US

V. Phone/Fax

Practice location:
  • Phone: 812-603-2309
  • Fax:
Mailing address:
  • Phone: 812-603-2309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5302043816
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: