Provider Demographics
NPI:1114666468
Name:DAVIS, KELLY (RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:PEPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8831 MORRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4180
Mailing Address - Country:US
Mailing Address - Phone:734-655-0562
Mailing Address - Fax:
Practice Address - Street 1:8831 MORRISON AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4180
Practice Address - Country:US
Practice Address - Phone:734-655-0562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704358456163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse