Provider Demographics
NPI:1508430083
Name:LYNCH, KAILEY DANIELLE
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:DANIELLE
Last Name:LYNCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAILEY
Other - Middle Name:DANIELLE
Other - Last Name:MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:504 ACADEMY RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-1535
Mailing Address - Country:US
Mailing Address - Phone:248-245-0278
Mailing Address - Fax:
Practice Address - Street 1:700 S MAIN ST STE 101B
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-3082
Practice Address - Country:US
Practice Address - Phone:810-969-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704320852363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty