Provider Demographics
NPI:1184260754
Name:AGUILERA, KELLY JO
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:AGUILERA
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 1:3985 E BROOKS RD
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48623-9436
Mailing Address - Country:US
Mailing Address - Phone:989-573-2464
Mailing Address - Fax:
Practice Address - Street 1:3985 E BROOKS RD
Practice Address - Street 2:
Practice Address - City:FREELAND
Practice Address - State:MI
Practice Address - Zip Code:48623-9436
Practice Address - Country:US
Practice Address - Phone:989-573-2464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7601000059207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics