Provider Demographics
NPI:1154434793
Name:HALL, KELLI STIDHAM (PHD, NP)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:STIDHAM
Last Name:HALL
Suffix:
Gender:F
Credentials:PHD, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 FLETCHER ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-1050
Mailing Address - Country:US
Mailing Address - Phone:859-533-0762
Mailing Address - Fax:
Practice Address - Street 1:207 FLETCHER ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-1050
Practice Address - Country:US
Practice Address - Phone:859-533-0762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704291265363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily