Provider Demographics
NPI:1396103016
Name:KELLY, SANDRA KAY (AGACNP)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:KAY
Last Name:KELLY
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49017-3307
Mailing Address - Country:US
Mailing Address - Phone:269-245-8446
Mailing Address - Fax:269-966-2485
Practice Address - Street 1:300 NORTH AVE
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3307
Practice Address - Country:US
Practice Address - Phone:269-245-8446
Practice Address - Fax:269-966-2485
Is Sole Proprietor?:No
Enumeration Date:2016-02-09
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704168821363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology