Provider Demographics
NPI:1245999432
Name:BAKER, KELSEY KATHERINE (CPNP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:KATHERINE
Last Name:BAKER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17700 25 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-1711
Mailing Address - Country:US
Mailing Address - Phone:586-785-9128
Mailing Address - Fax:
Practice Address - Street 1:3030 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-3819
Practice Address - Country:US
Practice Address - Phone:810-385-5995
Practice Address - Fax:810-385-9515
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704316627363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics