Provider Demographics
NPI:1730762246
Name:WAACK, KELCIE ANN (FNP)
Entity type:Individual
Prefix:MRS
First Name:KELCIE
Middle Name:ANN
Last Name:WAACK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19169 HANNAN RD
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48164-9371
Mailing Address - Country:US
Mailing Address - Phone:313-605-3418
Mailing Address - Fax:
Practice Address - Street 1:3 HERITAGE CENTER
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195
Practice Address - Country:US
Practice Address - Phone:734-283-3222
Practice Address - Fax:734-283-4006
Is Sole Proprietor?:No
Enumeration Date:2021-05-03
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704333571207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIF04210455Medicaid