Healthcare Provider Details

I. General information

NPI: 1487435533
Provider Name (Legal Business Name): KORTNIE MICHELE LYELL CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2023
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 FULLER RD
ANN ARBOR MI
48105-2303
US

IV. Provider business mailing address

16469 OAKBROOK ST
ROMULUS MI
48174-3231
US

V. Phone/Fax

Practice location:
  • Phone: 734-769-7100
  • Fax:
Mailing address:
  • Phone: 734-626-5034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303015512
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number10049304-PTCB
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: