MEDICARE: MRS. KELLIE MARIE WELLS PA

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	363AM0700X	Medical Physician Assistant	363AM0700X	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5601004711	OTHER	MI	BCBS STATE LICENSE

General Provider Information

NPI Number	:	1700832987
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLIE MARIE WELLS PA

Provider Business Mailing Address
First Line	:	1200 E MICHIGAN AVE STE 415
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48912-1897
Country	:	US
Telephone Number	:	517-484-2760
Fax Number	:	517-484-9370

Provider Business Practice Location Address
First Line	:	1200 E MICHIGAN AVE STE 415
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48912-1897
Country	:	US
Telephone Number	:	517-484-2760
Fax Number	:	517-484-9370

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

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	01/21/2013

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