Provider Demographics
NPI:1154888501
Name:ELDER, KAY (FNP-C)
Entity type:Individual
Prefix:
First Name:KAY
Middle Name:
Last Name:ELDER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22725 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1832
Mailing Address - Country:US
Mailing Address - Phone:313-522-6655
Mailing Address - Fax:
Practice Address - Street 1:20211 ANN ARBOR TRL
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2691
Practice Address - Country:US
Practice Address - Phone:313-336-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704224475163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty