Provider Demographics
NPI:1215344684
Name:KINSEY, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KINSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12158 N LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:LA SALLE
Mailing Address - State:MI
Mailing Address - Zip Code:48145-9733
Mailing Address - Country:US
Mailing Address - Phone:734-242-2081
Mailing Address - Fax:
Practice Address - Street 1:718 N MACOMB ST
Practice Address - Street 2:SUITE 225
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-7815
Practice Address - Country:US
Practice Address - Phone:734-242-2081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704280878363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health