Provider Demographics
NPI:1023561537
Name:BOUIE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BOUIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 BALDWIN CIR
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-9369
Mailing Address - Country:US
Mailing Address - Phone:248-343-1767
Mailing Address - Fax:
Practice Address - Street 1:3050 REGENT BLVD STE 200
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-5806
Practice Address - Country:US
Practice Address - Phone:214-689-8079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-01
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704242969363L00000X
MI2016013730363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner