Provider Demographics
NPI:1053991075
Name:VANDERBUSH, KELYNN (MA)
Entity type:Individual
Prefix:
First Name:KELYNN
Middle Name:
Last Name:VANDERBUSH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KELYNN
Other - Middle Name:
Other - Last Name:ROESER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:606 ANCHOR ST
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-1302
Mailing Address - Country:US
Mailing Address - Phone:989-313-0938
Mailing Address - Fax:
Practice Address - Street 1:655 E CEDAR AVE
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-2215
Practice Address - Country:US
Practice Address - Phone:989-313-0938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-13
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2824081172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker