Healthcare Provider Details

I. General information

NPI: 1164082285
Provider Name (Legal Business Name): KELLY HOPPER AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 S SAGINAW ST
FLINT MI
48507-2677
US

IV. Provider business mailing address

8123 TIPSICO TRL
HOLLY MI
48442-9144
US

V. Phone/Fax

Practice location:
  • Phone: 810-732-8336
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704283210
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: