Provider Demographics
NPI:1508085531
Name:WILSON, KELLEY GEDDIS (CNP)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:GEDDIS
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:STE 400
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:800-527-6266
Mailing Address - Fax:313-576-8381
Practice Address - Street 1:4100 JOHN R ST
Practice Address - Street 2:KARMANOS CANCER CENTER MIDLEVELS
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2013
Practice Address - Country:US
Practice Address - Phone:800-527-6266
Practice Address - Fax:313-576-8381
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704185213363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P32180050Medicare PIN
P34780061Medicare UPIN