Provider Demographics
NPI:1891725495
Name:BEAUDOIN, KELLI (PA)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:BEAUDOIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:CRAWFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:21031 MICHIGAN AVE
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2339
Mailing Address - Country:US
Mailing Address - Phone:313-277-6700
Mailing Address - Fax:313-216-0176
Practice Address - Street 1:18100 OAKWOOD BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4085
Practice Address - Country:US
Practice Address - Phone:313-429-7977
Practice Address - Fax:313-429-7981
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003485363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P32070017Medicare PIN