MEDICARE: KELLEY LYNNE GRAY-ALLEN P.A.

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	363A00000X	Physician Assistant	5601004915	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1074093	OTHER		NCCPA CERTIFICATE
2	5601004915	OTHER	MI	LICENSE

General Provider Information

NPI Number	:	1316029010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY LYNNE GRAY-ALLEN P.A.

Provider Business Mailing Address
First Line	:	35735 MOUND RD STE 100
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-4728
Country	:	US
Telephone Number	:	586-261-1960
Fax Number	:

Provider Business Practice Location Address
First Line	:	35735 MOUND RD STE 100
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48310-4728
Country	:	US
Telephone Number	:	586-261-1960
Fax Number	:

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

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	06/13/2024

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Directions to “ KELLEY LYNNE GRAY-ALLEN P.A.” Practice Location

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