MEDICARE: KRISTI ILLIS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WA0400X	Addiction (Substance Use Disorder) Registered Nurse	4704252014	MI

General Provider Information

NPI Number	:	1356746127
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTI ILLIS RN

Provider Business Mailing Address
First Line	:	522 S MAPLE RD
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48103-3837
Country	:	US
Telephone Number	:	734-585-7970
Fax Number	:

Provider Business Practice Location Address
First Line	:	522 S MAPLE RD
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48103-3837
Country	:	US
Telephone Number	:	734-585-7970
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2014
Last Update Date	:	10/23/2014

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