Provider Demographics
NPI:1174155063
Name:SALIK, KELLY RAYE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RAYE
Last Name:SALIK
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 1:8165 DIETZ RD
Mailing Address - Street 2:
Mailing Address - City:BELDING
Mailing Address - State:MI
Mailing Address - Zip Code:48809-9408
Mailing Address - Country:US
Mailing Address - Phone:616-894-4568
Mailing Address - Fax:
Practice Address - Street 1:3097 PRAIRIE ST SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2000
Practice Address - Country:US
Practice Address - Phone:616-531-9973
Practice Address - Fax:616-531-5577
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704206999163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704206999Medicaid