Provider Demographics
NPI:1871825703
Name:SUMMERFIELD, KELLY JEAN (CNM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:SUMMERFIELD
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 N TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3222
Mailing Address - Country:US
Mailing Address - Phone:313-561-2200
Mailing Address - Fax:313-561-2211
Practice Address - Street 1:6221 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3222
Practice Address - Country:US
Practice Address - Phone:313-561-2200
Practice Address - Fax:313-561-2211
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704213133367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Q26334063Medicare PIN