Healthcare Provider Details

I. General information

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

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22170 W 9 MILE RD
SOUTHFIELD MI
48033-6007
US

IV. Provider business mailing address

PO BOX 263
HAZEL PARK MI
48030-0263
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2026038460
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704406880
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: