Healthcare Provider Details

I. General information

NPI: 1548059769
Provider Name (Legal Business Name): KELLY ANNE LUSK
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 EAST KEARSLEY STREET 4125 WILLIAM S. WHITE BUILDING
FLINT MI
48502
US

IV. Provider business mailing address

27986 GAINES MILL WAY
FARMINGTON HILLS MI
48331-3107
US

V. Phone/Fax

Practice location:
  • Phone: 248-595-4916
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number4704371979
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: