Healthcare Provider Details

I. General information

NPI: 1992119085
Provider Name (Legal Business Name): KELSEY ELYSE PENEBAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2992 BIRCH HOLLOW DR APT 1B
ANN ARBOR MI
48108-2336
US

IV. Provider business mailing address

2992 BIRCH HOLLOW DR APT 1B
ANN ARBOR MI
48108-2336
US

V. Phone/Fax

Practice location:
  • Phone: 414-975-4436
  • Fax:
Mailing address:
  • Phone: 414-975-4436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001295
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: