Provider Demographics
NPI:1083296834
Name:KROLL, KELLIE RAE (CPNP-PC)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:RAE
Last Name:KROLL
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1992 WILTSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-3313
Mailing Address - Country:US
Mailing Address - Phone:248-320-4828
Mailing Address - Fax:
Practice Address - Street 1:8623 N WAYNE RD STE 123
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-1137
Practice Address - Country:US
Practice Address - Phone:734-367-0469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704294238NSA2001Q363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner