Provider Demographics
NPI:1629581970
Name:KELLY, CAITLIN MARIE (AG-ACNP)
Entity Type:Individual
Prefix:MRS
First Name:CAITLIN
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:AG-ACNP
Other - Prefix:MS
Other - First Name:CAITLIN
Other - Middle Name:MARIE
Other - Last Name:SHEARDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AG-ACNP
Mailing Address - Street 1:30025 CHAMPINE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082-1653
Mailing Address - Country:US
Mailing Address - Phone:586-504-0296
Mailing Address - Fax:
Practice Address - Street 1:29001 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-2711
Practice Address - Country:US
Practice Address - Phone:586-778-0664
Practice Address - Fax:586-778-0396
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704299955363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care