Provider Demographics
NPI:1467044941
Name:KATTELUS, KYLIE J (FNP)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:J
Last Name:KATTELUS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 N SHIAWASSEE ST STE 110
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-1601
Mailing Address - Country:US
Mailing Address - Phone:989-723-1390
Mailing Address - Fax:989-725-1415
Practice Address - Street 1:819 N SHIAWASSEE ST STE 110
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-1601
Practice Address - Country:US
Practice Address - Phone:989-723-1390
Practice Address - Fax:989-725-1415
Is Sole Proprietor?:No
Enumeration Date:2021-02-06
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704275840363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1467044941Medicaid