Provider Demographics
NPI:1386388809
Name:VOGEL, KELLY RAE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RAE
Last Name:VOGEL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 QUIGLEY PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-4406
Mailing Address - Country:US
Mailing Address - Phone:519-067-8919
Mailing Address - Fax:
Practice Address - Street 1:100 NAVARRE PLACE
Practice Address - Street 2:SUITE 4470
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601
Practice Address - Country:US
Practice Address - Phone:574-647-1405
Practice Address - Fax:574-647-3970
Is Sole Proprietor?:No
Enumeration Date:2022-04-21
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28239544A176B00000X
IN71016343A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife