Provider Demographics
NPI:1962421289
Name:GILLIS, KELLIE JEAN (DC)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:JEAN
Last Name:GILLIS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MI
Mailing Address - Zip Code:49837-1504
Mailing Address - Country:US
Mailing Address - Phone:906-428-2225
Mailing Address - Fax:906-428-9778
Practice Address - Street 1:8 S 11TH ST
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MI
Practice Address - Zip Code:49837-1504
Practice Address - Country:US
Practice Address - Phone:906-428-2225
Practice Address - Fax:906-428-9778
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009040111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor