Healthcare Provider Details

I. General information

NPI: 1043672587
Provider Name (Legal Business Name): KELLY MAGRUM NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 12/25/2024
Certification Date: 12/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 STEWART RD
MONROE MI
48162-4222
US

IV. Provider business mailing address

1 SEAGATE STE 800
TOLEDO OH
43604-1558
US

V. Phone/Fax

Practice location:
  • Phone: 734-240-8430
  • Fax:
Mailing address:
  • Phone: 419-367-9691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number4704260469
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704260469
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: