MEDICARE: KELLY SHAFER NP

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	363LF0000X	Family Nurse Practitioner	4704272276	MI

General Provider Information

NPI Number	:	1417326786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY SHAFER NP

Provider Business Mailing Address
First Line	:	26901 BEAUMONT BLVD
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48033-3849
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2115 25 MILE RD
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-1097
Country	:	US
Telephone Number	:	866-389-2727
Fax Number	:

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

Provider Enumeration Date	:	09/17/2015
Last Update Date	:	05/18/2022

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