Healthcare Provider Details

I. General information

NPI: 1003735887
Provider Name (Legal Business Name): MRS. KELSEY MELLON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 E H ST
IRON MOUNTAIN MI
49801-4760
US

IV. Provider business mailing address

325 E H ST
IRON MOUNTAIN MI
49801-4760
US

V. Phone/Fax

Practice location:
  • Phone: 906-774-3300
  • Fax: 906-779-3130
Mailing address:
  • Phone: 906-774-3300
  • Fax: 906-779-3130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number195148-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704318409
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: