Provider Demographics
NPI:1548055098
Name:PAGE, KELLY (LPN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PAGE
Suffix:
Gender:
Credentials:LPN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:WOODWORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19611 E 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1655
Mailing Address - Country:US
Mailing Address - Phone:586-541-9550
Mailing Address - Fax:
Practice Address - Street 1:19611 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1655
Practice Address - Country:US
Practice Address - Phone:586-541-9550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-14
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703120562164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse