Provider Demographics
NPI:1679844104
Name:KELLY, THERESA (PA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:49540 NAUTICAL DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-2334
Mailing Address - Country:US
Mailing Address - Phone:248-767-8456
Mailing Address - Fax:
Practice Address - Street 1:43200 DEQUINDRE RD
Practice Address - Street 2:STE104
Practice Address - City:STERLING HTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1707
Practice Address - Country:US
Practice Address - Phone:586-799-4350
Practice Address - Fax:586-799-4279
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601006213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601006213OtherSTATE LICENSE