Provider Demographics
NPI:1487435533
Name:LYELL, KORTNIE MICHELE (CPHT)
Entity type:Individual
Prefix:
First Name:KORTNIE
Middle Name:MICHELE
Last Name:LYELL
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16469 OAKBROOK ST
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-3231
Mailing Address - Country:US
Mailing Address - Phone:734-626-5034
Mailing Address - Fax:
Practice Address - Street 1:2215 FULLER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-2303
Practice Address - Country:US
Practice Address - Phone:734-769-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303015512183700000X
MI10049304-PTCB183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician