MEDICARE: KELLY EATON-KELLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	474235719	MI

General Provider Information

NPI Number	:	1992211544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY EATON-KELLEY

Provider Business Mailing Address
First Line	:	1137 MORELAND ST
Second Line	:
City	:	GRAND HAVEN
State	:	MI
Zip	:	49417-2821
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1137 MORELAND ST
Second Line	:
City	:	GRAND HAVEN
State	:	MI
Zip	:	49417-2821
Country	:	US
Telephone Number	:	616-607-8030
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2017
Last Update Date	:	12/19/2017

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Directions to “ KELLY EATON-KELLEY ” Practice Location

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