=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821574369
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELCEY GOODWIN GUERRIERO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2018
-----------------------------------------------------
Last Update Date | 04/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5500 AUTO CLUB DR
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-653-6568
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14869 MCLAIN AVE
-----------------------------------------------------
City | ALLEN PARK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48101-1816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-693-6076
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 4704277474
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 4704277474
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------