MEDICARE: KATELYN KHEMMORO

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1558232454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATELYN KHEMMORO

Provider Business Mailing Address
First Line	:	2926 MONTGOMERY CIR
Second Line	:
City	:	WALLED LAKE
State	:	MI
Zip	:	48390-3605
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2926 MONTGOMERY CIR
Second Line	:
City	:	WALLED LAKE
State	:	MI
Zip	:	48390-3605
Country	:	US
Telephone Number	:	248-762-3297
Fax Number	:

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

Provider Enumeration Date	:	09/15/2025
Last Update Date	:	09/15/2025

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Directions to “ KATELYN KHEMMORO ” Practice Location

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