Healthcare Provider Details

I. General information

NPI: 1861975476
Provider Name (Legal Business Name): KELLY SCHULTZ PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY VIGANSKY PA-C

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 AIRVIEW BLVD STE 105
PORTAGE MI
49002-1804
US

IV. Provider business mailing address

PO BOX 40412
BELFAST ME
04915-1255
US

V. Phone/Fax

Practice location:
  • Phone: 269-349-8386
  • Fax: 269-349-8397
Mailing address:
  • Phone: 248-824-6500
  • Fax: 855-618-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008809
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: