Basic Information
| Provider Information | |||||||||
| NPI: | 1568877694 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EXUM | ||||||||
| FirstName: | KELLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 585 JEWETT RD | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488548729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176765405 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4400 S SAGINAW ST STE 1460 | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485072664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102370799 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2014 | ||||||||
| LastUpdateDate: | 06/27/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.