Provider Demographics
NPI:1003121120
Name:FOGARTY, KELLI NICOLE (RN)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:NICOLE
Last Name:FOGARTY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:765 KESTREL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-2027
Mailing Address - Country:US
Mailing Address - Phone:734-624-9938
Mailing Address - Fax:
Practice Address - Street 1:2087 HIDDEN LN
Practice Address - Street 2:
Practice Address - City:LEONARD
Practice Address - State:MI
Practice Address - Zip Code:48367-3225
Practice Address - Country:US
Practice Address - Phone:734-624-9938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-12
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704254681163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health