Provider Demographics
NPI:1528462702
Name:BURRI, KELLY MARISSA (NP-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARISSA
Last Name:BURRI
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:MARISSA
Other - Last Name:VANDER PLOEG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:664 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4944
Mailing Address - Country:US
Mailing Address - Phone:616-392-5973
Mailing Address - Fax:616-392-1646
Practice Address - Street 1:664 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4944
Practice Address - Country:US
Practice Address - Phone:616-392-5973
Practice Address - Fax:616-392-1646
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-16
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704247029363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily