Provider Demographics
NPI:1215613005
Name:ALLEN, KELLI MARIE
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:ALLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17616 PENNINGTON DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221
Mailing Address - Country:US
Mailing Address - Phone:313-829-3053
Mailing Address - Fax:
Practice Address - Street 1:17616 PENNINGTON DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221
Practice Address - Country:US
Practice Address - Phone:313-829-3053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health