MEDICARE: MRS. KELLEY LYNN ILLIS 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	163W00000X	Registered Nurse	4704308851	MI

General Provider Information

NPI Number	:	1114317773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLEY LYNN ILLIS RN

Provider Business Mailing Address
First Line	:	522 S MAPLE RD
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48103-3837
Country	:	US
Telephone Number	:	734-585-7958
Fax Number	:

Provider Business Practice Location Address
First Line	:	522 S MAPLE RD
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48103-3837
Country	:	US
Telephone Number	:	734-585-7958
Fax Number	:

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

Provider Enumeration Date	:	02/03/2015
Last Update Date	:	02/03/2015

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