Healthcare Provider Details

I. General information

NPI: 1083443105
Provider Name (Legal Business Name): KELCY ELIZABETH FRITZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-4800
  • Fax:
Mailing address:
  • Phone: 517-581-5798
  • Fax: 313-876-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704300588
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704300588
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: