Provider Demographics
NPI:1093167090
Name:DUNN, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DUNN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3791 EASTBOURNE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1500 W BIG BEAVER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3522
Practice Address - Country:US
Practice Address - Phone:248-689-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-01
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007820363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant