Provider Demographics
NPI:1487878443
Name:DE SIEYES, KELLY ANNE (CDM, CPM)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANNE
Last Name:DE SIEYES
Suffix:
Gender:F
Credentials:CDM, CPM
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:ANNE
Other - Last Name:COLEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:154 W MARYDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7501
Mailing Address - Country:US
Mailing Address - Phone:907-262-9446
Mailing Address - Fax:907-262-9354
Practice Address - Street 1:154 W MARYDALE AVE
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7501
Practice Address - Country:US
Practice Address - Phone:907-262-9446
Practice Address - Fax:907-262-9354
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK30176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNM41812Medicaid