Healthcare Provider Details

I. General information

NPI: 1922915677
Provider Name (Legal Business Name): KELSEY RENEE VITTITOW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 CHIPPEWA ST
KAWKAWLIN MI
48631-9206
US

IV. Provider business mailing address

125 CHIPPEWA ST
KAWKAWLIN MI
48631-9206
US

V. Phone/Fax

Practice location:
  • Phone: 989-439-4693
  • Fax:
Mailing address:
  • Phone: 989-439-4693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601014236
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: