Provider Demographics
NPI:1508480021
Name:BOHL, KELSEY MARIE (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:BOHL
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:MARIE
Other - Last Name:OWENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:24400 GREATER MACK AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1340
Mailing Address - Country:US
Mailing Address - Phone:586-778-1881
Mailing Address - Fax:586-778-0667
Practice Address - Street 1:24400 GREATER MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1340
Practice Address - Country:US
Practice Address - Phone:586-778-1881
Practice Address - Fax:586-778-0667
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009939363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant