Healthcare Provider Details

I. General information

NPI: 1659761054
Provider Name (Legal Business Name): KELLY WALKER N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 11/27/2023
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6220 W MAIN ST
KALAMAZOO MI
49009-8925
US

IV. Provider business mailing address

17335 OLEANDER AVE
TINLEY PARK IL
60477-3226
US

V. Phone/Fax

Practice location:
  • Phone: 269-276-4744
  • Fax: 269-353-5856
Mailing address:
  • Phone: 708-710-0737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704309024
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: