Healthcare Provider Details

I. General information

NPI: 1619078011
Provider Name (Legal Business Name): KELLY NICOLE HOBSON N.P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 TOWN CTR STE 1506
SOUTHFIELD MI
48075-1115
US

IV. Provider business mailing address

21411 CIVIC CENTER DR STE 201
SOUTHFIELD MI
48076-3950
US

V. Phone/Fax

Practice location:
  • Phone: 248-417-1008
  • Fax:
Mailing address:
  • Phone: 248-417-1008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704210540
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: