Healthcare Provider Details

I. General information

NPI: 1912642851
Provider Name (Legal Business Name): KELSEY BLUE NUSBAUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELSEY BLUE KEYSER

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5199 N ROYAL DR
TRAVERSE CITY MI
49684-9201
US

IV. Provider business mailing address

5199 N ROYAL DR
TRAVERSE CITY MI
49684-9201
US

V. Phone/Fax

Practice location:
  • Phone: 231-486-0230
  • Fax:
Mailing address:
  • Phone: 231-486-0230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number4301517943
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: