Provider Demographics
NPI:1548059769
Name:LUSK, KELLY ANNE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:LUSK
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27986 GAINES MILL WAY
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-3107
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 EAST KEARSLEY STREET
Practice Address - Street 2:4125 WILLIAM S. WHITE BUILDING
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502
Practice Address - Country:US
Practice Address - Phone:248-595-4916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-05
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704371979163WC0200X, 163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine