Provider Demographics
NPI:1902287584
Name:HARDY, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HARDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 BAYBERRY POINTE DR NW
Mailing Address - Street 2:APT L
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-4678
Mailing Address - Country:US
Mailing Address - Phone:616-304-6996
Mailing Address - Fax:
Practice Address - Street 1:449 BAYBERRY POINTE DR NW
Practice Address - Street 2:APT L
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-4678
Practice Address - Country:US
Practice Address - Phone:616-304-6996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010010532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer