Provider Demographics
NPI:1386851228
Name:PAGEL, KELLI ANN (PAC)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:ANN
Last Name:PAGEL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23660 EUREKA RD
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-5275
Mailing Address - Country:US
Mailing Address - Phone:734-250-9630
Mailing Address - Fax:734-250-9631
Practice Address - Street 1:23660 EUREKA RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-5275
Practice Address - Country:US
Practice Address - Phone:734-250-9630
Practice Address - Fax:734-250-9631
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005021363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005021OtherSTATE LICENSE NUMBER