Provider Demographics
NPI:1992484422
Name:POWLISHEN, KELLY ANN (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:POWLISHEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 MACK AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2466
Mailing Address - Country:US
Mailing Address - Phone:313-832-0500
Mailing Address - Fax:313-745-1316
Practice Address - Street 1:311 MACK AVE FL 5
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2466
Practice Address - Country:US
Practice Address - Phone:313-832-0500
Practice Address - Fax:313-745-1316
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
MI5601011765363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical