Healthcare Provider Details

I. General information

NPI: 1952848301
Provider Name (Legal Business Name): TIMOTHY JAMES KELLIE CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2017
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 N MACOMB ST STE 3
MONROE MI
48162-3076
US

IV. Provider business mailing address

905 N MACOMB ST STE 3
MONROE MI
48162-3076
US

V. Phone/Fax

Practice location:
  • Phone: 734-241-0560
  • Fax: 734-241-3230
Mailing address:
  • Phone: 734-241-0560
  • Fax: 734-241-3230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704285899
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WM1400X
TaxonomyNurse Massage Therapist (NMT)
License Number7501000754
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7501000754
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704285899
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: