Basic Information
| Provider Information | |||||||||
| NPI: | 1083296834 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KROLL | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | RAE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CPNP-PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1992 WILTSHIRE RD | ||||||||
| Address2: | |||||||||
| City: | BERKLEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480723313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483204828 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8623 N WAYNE RD STE 123 | ||||||||
| Address2: | |||||||||
| City: | WESTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481851137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343670469 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2021 | ||||||||
| LastUpdateDate: | 04/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4704294238NSA2001Q | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.