Provider Demographics
NPI:1497486021
Name:BURGER, KELLY LOUISE
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:LOUISE
Last Name:BURGER
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 1:4350 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-3506
Mailing Address - Country:US
Mailing Address - Phone:248-674-0466
Mailing Address - Fax:248-674-0466
Practice Address - Street 1:4350 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-3506
Practice Address - Country:US
Practice Address - Phone:248-674-0466
Practice Address - Fax:248-674-0466
Is Sole Proprietor?:No
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303035366183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician