Provider Demographics
NPI:1922512292
Name:THORNBURG, KELLI RAE (LPN, WOCN)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:RAE
Last Name:THORNBURG
Suffix:
Gender:F
Credentials:LPN, WOCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7820 WHITTAKER RD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-9775
Mailing Address - Country:US
Mailing Address - Phone:734-660-8183
Mailing Address - Fax:734-547-5832
Practice Address - Street 1:7820 WHITTAKER RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-9775
Practice Address - Country:US
Practice Address - Phone:734-660-8183
Practice Address - Fax:734-547-5832
Is Sole Proprietor?:No
Enumeration Date:2017-11-25
Last Update Date:2017-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703105850164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse