Healthcare Provider Details

I. General information

NPI: 1093644916
Provider Name (Legal Business Name): KELLY DUNSMORE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34454 POTTER ST
MEMPHIS MI
48041-4658
US

IV. Provider business mailing address

34454 POTTER ST
MEMPHIS MI
48041-4658
US

V. Phone/Fax

Practice location:
  • Phone: 810-858-2251
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5601014007
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: