Provider Demographics
NPI:1164167805
Name:JOA, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:JOA
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 1:10270 CLARK RD
Mailing Address - Street 2:
Mailing Address - City:DAVISBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48350-2708
Mailing Address - Country:US
Mailing Address - Phone:586-314-0080
Mailing Address - Fax:877-673-3562
Practice Address - Street 1:50505 SCHOENHERR RD STE 290
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-3141
Practice Address - Country:US
Practice Address - Phone:586-314-0080
Practice Address - Fax:877-673-3562
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704323061163W00000X, 363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner