Healthcare Provider Details

I. General information

NPI: 1548767973
Provider Name (Legal Business Name): KELLY JAYNE MCCARTHY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 VIKING CIR
COMMERCE TOWNSHIP MI
48390-1579
US

IV. Provider business mailing address

1911 VIKING CIR
COMMERCE TOWNSHIP MI
48390-1579
US

V. Phone/Fax

Practice location:
  • Phone: 248-719-5889
  • Fax:
Mailing address:
  • Phone: 248-719-5889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704303843
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704303843
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: