Provider Demographics
NPI:1144721804
Name:DEDENBACH, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DEDENBACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-5674
Mailing Address - Country:US
Mailing Address - Phone:313-820-8064
Mailing Address - Fax:
Practice Address - Street 1:250 WINDSOR RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-3882
Practice Address - Country:US
Practice Address - Phone:313-820-8064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty