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General NPI Number Information
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NPI Number | 1629581970
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Entity Type | Individual
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Provider Name | CAITLIN MARIE KELLY AG-ACNP
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Gender | Female
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Dates
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Enumeration Date | 11/08/2017
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Last Update Date | 04/23/2019
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Provider Practice Location Address
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Address Line | 29001 HARPER AVE
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City | SAINT CLAIR SHORES
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State | MI
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Zip | 48081-2711
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Country | US
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Telephone | 586-778-0664
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Fax | 586-778-0396
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Provider Business Mailing Address
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Address Line | 30025 CHAMPINE ST
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City | SAINT CLAIR SHORES
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State | MI
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Zip | 48082-1653
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Country | US
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Telephone | 586-504-0296
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | 4704299955
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License Number State | MI
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