Provider Demographics
NPI:1043672587
Name:MAGRUM, KELLY (NP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MAGRUM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SEAGATE
Mailing Address - Street 2:STE 800
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1558
Mailing Address - Country:US
Mailing Address - Phone:419-367-9691
Mailing Address - Fax:
Practice Address - Street 1:650 STEWART RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-4222
Practice Address - Country:US
Practice Address - Phone:734-240-8430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2024-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704260469207QA0505X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine