Provider Demographics
NPI:1770621328
Name:MARKOWSKI, KELLEY ANN (NP)
Entity type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:ANN
Last Name:MARKOWSKI
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24691 CHRISTIAN DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN
Mailing Address - State:MI
Mailing Address - Zip Code:48134-9115
Mailing Address - Country:US
Mailing Address - Phone:734-782-2133
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:734-246-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2021-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704184417363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4832463Medicaid
MIP30500002Medicare ID - Type Unspecified