Healthcare Provider Details

I. General information

NPI: 1386609543
Provider Name (Legal Business Name): KELLIE DISTEFANO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S CENTER ST
HARTFORD MI
49057-1362
US

IV. Provider business mailing address

400 MEDICAL PARK DR
WATERVLIET MI
49098-9225
US

V. Phone/Fax

Practice location:
  • Phone: 269-621-4063
  • Fax: 269-621-9972
Mailing address:
  • Phone: 269-463-2431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5601002464
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601002464
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: