Healthcare Provider Details

I. General information

NPI: 1851202642
Provider Name (Legal Business Name): KELSEY L TAIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6531 EAGLE RIDGE RD
BETTENDORF IA
52722-6266
US

IV. Provider business mailing address

6531 EAGLE RIDGE RD
BETTENDORF IA
52722-6266
US

V. Phone/Fax

Practice location:
  • Phone: 248-884-8446
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.468799
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: