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NPI Code Detail

MEDICARE: MS. ANNALIESE GRACE KHEMMORO

MEDICARE: MS. ANNALIESE GRACE KHEMMORO
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
1363A00000XPhysician Assistant5601012844MI

General Provider Information

NPI Number : 1548076268
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. ANNALIESE GRACE KHEMMORO
Provider Business Mailing Address
First Line : 18000 W 9 MILE RD STE 200
Second Line :
City : SOUTHFIELD
State : MI
Zip : 48075-4020
Country : US
Telephone Number : 248-336-4000
Fax Number : 248-336-9137
Provider Business Practice Location Address
First Line : 911 E 9 MILE RD
Second Line :
City : FERNDALE
State : MI
Zip : 48220-1934
Country : US
Telephone Number : 248-336-4000
Fax Number : 248-336-9137
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/06/2024
Last Update Date : 12/16/2025

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Directions to “ MS. ANNALIESE GRACE KHEMMORO ” Practice Location

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