Provider Demographics
NPI:1205204385
Name:BACKERS, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BACKERS
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 1:1012 W HURON ST
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328-3730
Mailing Address - Country:US
Mailing Address - Phone:248-681-1880
Mailing Address - Fax:
Practice Address - Street 1:1012 W HURON ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-3730
Practice Address - Country:US
Practice Address - Phone:248-681-1880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007474363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant