MEDICARE: KELLI NICOLE FOGARTY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WH0200X	Home Health Registered Nurse	4704254681	MI

General Provider Information

NPI Number	:	1003121120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI NICOLE FOGARTY RN

Provider Business Mailing Address
First Line	:	765 KESTREL RIDGE DR
Second Line	:
City	:	SOUTH LYON
State	:	MI
Zip	:	48178-2027
Country	:	US
Telephone Number	:	734-624-9938
Fax Number	:

Provider Business Practice Location Address
First Line	:	2087 HIDDEN LN
Second Line	:
City	:	LEONARD
State	:	MI
Zip	:	48367-3225
Country	:	US
Telephone Number	:	734-624-9938
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2010
Last Update Date	:	08/31/2010

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