Individual
KELLY ROSE MIKAIL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
4100 LAKE DR SE, SUITE 200, GRAND RAPIDS, MI 49546-8292
(616) 267-7293
(616) 267-7228
Mailing address
100 MICHIGAN ST NE, MC845, GRAND RAPIDS, MI 49503-2560
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
5601005774
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1497075766
—
MI
Enumeration date
06/09/2010
Last updated
02/18/2021
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