Provider Demographics
NPI:1811789894
Name:HANNER, KELLY LEE (MSN RN, LMT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEE
Last Name:HANNER
Suffix:
Gender:F
Credentials:MSN RN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ELM ST STE C
Mailing Address - Street 2:
Mailing Address - City:BIG RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49307-1802
Mailing Address - Country:US
Mailing Address - Phone:231-598-9144
Mailing Address - Fax:
Practice Address - Street 1:110 ELM ST STE C
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-1802
Practice Address - Country:US
Practice Address - Phone:231-598-9144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704280951163WM1400X, 163W00000X
171400000X, 174H00000X
MI7501016036225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)
No163W00000XNursing Service ProvidersRegistered Nurse
No171400000XOther Service ProvidersHealth & Wellness Coach
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist