Provider Demographics
NPI:1992339311
Name:NIEZURAWSKI, KELLY R (NP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:NIEZURAWSKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 175
Mailing Address - Street 2:
Mailing Address - City:MANITOU BEACH
Mailing Address - State:MI
Mailing Address - Zip Code:49253-0175
Mailing Address - Country:US
Mailing Address - Phone:517-403-3771
Mailing Address - Fax:
Practice Address - Street 1:6500 N HAWKINS HWY
Practice Address - Street 2:
Practice Address - City:MANITOU BEACH
Practice Address - State:MI
Practice Address - Zip Code:49253-9736
Practice Address - Country:US
Practice Address - Phone:734-572-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-25
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704187362363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner