Provider Demographics
NPI:1912728023
Name:CARROLL, KELLY ANNE (FNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2135 STONINGTON LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306-3164
Mailing Address - Country:US
Mailing Address - Phone:248-550-6646
Mailing Address - Fax:
Practice Address - Street 1:17330 NORTHLAND PARK CT
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4318
Practice Address - Country:US
Practice Address - Phone:248-552-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704305869363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily