Provider Demographics
NPI:1699053868
Name:KELLY, MARY KATE (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATE
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:248-324-1477
Practice Address - Street 1:16600 W SPRAGUE RD
Practice Address - Street 2:SUITE 120
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-6318
Practice Address - Country:US
Practice Address - Phone:440-826-0500
Practice Address - Fax:440-826-0501
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OHRN209986363LA2200X
OHCOA.12773-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health