Healthcare Provider Details

I. General information

NPI: 1508649559
Provider Name (Legal Business Name): KELLEY KUMMER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22170 W 9 MILE RD
SOUTHFIELD MI
48033-6007
US

IV. Provider business mailing address

390 W MADGE AVE
HAZEL PARK MI
48030-2043
US

V. Phone/Fax

Practice location:
  • Phone: 248-372-6980
  • Fax: 248-355-1402
Mailing address:
  • Phone: 313-506-7888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704406880
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: