Basic Information
Provider Information | |||||||||
NPI: | 1669581161 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FLORIANO | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: | RAE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROCHON | ||||||||
OtherFirstName: | KELLY | ||||||||
OtherMiddleName: | RAE | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | P.A. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 549 | ||||||||
Address2: |   | ||||||||
City: | IRON MOUNTAIN | ||||||||
State: | MI | ||||||||
PostalCode: | 498010549 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9067741313 | ||||||||
FaxNumber: | 9067765639 | ||||||||
Practice Location | |||||||||
Address1: | 1711 S STEPHENSON AVE | ||||||||
Address2: | SUITE 225 | ||||||||
City: | IRON MOUNTAIN | ||||||||
State: | MI | ||||||||
PostalCode: | 498013639 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9067765860 | ||||||||
FaxNumber: | 9067765833 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/29/2006 | ||||||||
LastUpdateDate: | 04/01/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/01/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601003478 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 5220024 | 01 | MI | BCBSM PIN | OTHER | 381875190 | 01 | MI | TAX IDENTIFICATION NUMBER | OTHER | 5601003478 | 01 | MI | PHYSICIANS ASSIST LICENSE | OTHER | 0852915090 | 01 | MI | BCBS PIN NUMBER | OTHER | P01025991 | 01 | MI | RR MEDICARE | OTHER | MR0945571 | 01 | MI | DEA REGISTRATION NUMBER | OTHER |