Provider Demographics
NPI:1104934496
Name:WILCOX-DEGRAAF, KELLI ANNE (DC)
Entity type:Individual
Prefix:DR
First Name:KELLI
Middle Name:ANNE
Last Name:WILCOX-DEGRAAF
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 ALPINE AVE NW
Mailing Address - Street 2:
Mailing Address - City:COMSTOCK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:49321-9717
Mailing Address - Country:US
Mailing Address - Phone:616-784-5433
Mailing Address - Fax:616-784-3577
Practice Address - Street 1:5900 ALPINE AVE NW
Practice Address - Street 2:
Practice Address - City:COMSTOCK PARK
Practice Address - State:MI
Practice Address - Zip Code:49321-9717
Practice Address - Country:US
Practice Address - Phone:616-784-5433
Practice Address - Fax:616-784-3577
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009030111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0D11549OtherBLUE CROSS BLUE SHIELD OF MICHIGAN