Provider Demographics
NPI:1679159925
Name:GINGRAS, KELLY (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GINGRAS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 LAFRANIER RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-4765
Mailing Address - Country:US
Mailing Address - Phone:231-995-6148
Mailing Address - Fax:
Practice Address - Street 1:2600 LAFRANIER RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4765
Practice Address - Country:US
Practice Address - Phone:231-995-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704314487363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health