Healthcare Provider Details

I. General information

NPI: 1134598816
Provider Name (Legal Business Name): MANDY KELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3231 S GULLEY RD SUITE E
DEARBORN MI
48124-4407
US

IV. Provider business mailing address

136 WILLIAM ST
SPRINGFIELD MA
01105-2324
US

V. Phone/Fax

Practice location:
  • Phone: 313-278-2327
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: