Healthcare Provider Details

I. General information

NPI: 1760124176
Provider Name (Legal Business Name): KRISTEN NICOLE GILLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTEN NICOLE CODY PA-C

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 10/10/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4294 LAUREL DR
LAKE ODESSA MI
48849-8430
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-374-7660
  • Fax:
Mailing address:
  • Phone: 616-486-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010969
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: