Healthcare Provider Details

I. General information

NPI: 1821232455
Provider Name (Legal Business Name): KELLY ANNE WATERS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 LAKE DR SE STE 200
GRAND RAPIDS MI
49546-8292
US

IV. Provider business mailing address

100 MICHIGAN ST NE MC 845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-3759
  • Fax: 616-391-3052
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number4301104008
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number4301104008
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: