Provider Demographics
NPI:1952848301
Name:KELLIE, TIMOTHY JAMES (CNP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:KELLIE
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 N MACOMB ST STE 3
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-3076
Mailing Address - Country:US
Mailing Address - Phone:734-241-0560
Mailing Address - Fax:734-241-3230
Practice Address - Street 1:905 N MACOMB ST STE 3
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3076
Practice Address - Country:US
Practice Address - Phone:734-241-0560
Practice Address - Fax:734-241-3230
Is Sole Proprietor?:No
Enumeration Date:2017-01-24
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704285899163W00000X, 363L00000X
MI7501000754163WM1400X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist