Provider Demographics
NPI:1144585472
Name:KELLEY, AUDREY ANN (ADMINISTRATOR)
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:ANN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:ADMINISTRATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22401 LYNDON ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-1856
Mailing Address - Country:US
Mailing Address - Phone:313-641-8054
Mailing Address - Fax:
Practice Address - Street 1:22401 LYNDON ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-1856
Practice Address - Country:US
Practice Address - Phone:131-364-1805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI104100000X
MI236666620390376K00000X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes376K00000XNursing Service Related ProvidersNurse's Aide