Provider Demographics
NPI:1285714725
Name:BRIZENDINE, KELLY LYNN (PAC)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:BRIZENDINE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 CAPITAL AVE SW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-4185
Mailing Address - Country:US
Mailing Address - Phone:269-969-6177
Mailing Address - Fax:269-969-8776
Practice Address - Street 1:2845 CAPITAL AVE SW
Practice Address - Street 2:SUITE 201
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-4185
Practice Address - Country:US
Practice Address - Phone:269-969-6177
Practice Address - Fax:269-969-8776
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004377363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP01450004Medicare ID - Type Unspecified
Q58995Medicare UPIN