Provider Demographics
NPI:1689097446
Name:WILLIAMS, KELLY (RN)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18889 SAINT AUBIN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-1220
Mailing Address - Country:US
Mailing Address - Phone:313-244-1700
Mailing Address - Fax:
Practice Address - Street 1:18889 SAINT AUBIN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-1220
Practice Address - Country:US
Practice Address - Phone:313-244-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704295197163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse