Provider Demographics
NPI:1881044279
Name:REILLY, ANN
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 DOVER HILLS DR APT 203
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-1460
Mailing Address - Country:US
Mailing Address - Phone:313-806-1725
Mailing Address - Fax:
Practice Address - Street 1:4711 DOVER HILLS DR APT 203
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1460
Practice Address - Country:US
Practice Address - Phone:313-806-1725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator