Provider Demographics
NPI:1265033831
Name:CROMERKENNEDY, SHELLY (RN)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:
Last Name:CROMERKENNEDY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:SHELLY
Other - Middle Name:
Other - Last Name:CROMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3200 GREENFIELD RD STE 200
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1802
Mailing Address - Country:US
Mailing Address - Phone:248-200-6290
Mailing Address - Fax:
Practice Address - Street 1:14583 ARCHDALE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-1441
Practice Address - Country:US
Practice Address - Phone:248-200-6290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704259456163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice