Provider Demographics
NPI:1053554758
Name:GILLISPIE, KELLI GAIL
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:GAIL
Last Name:GILLISPIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:GAIL
Other - Last Name:CATTERFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7406 PHEASANT RUN
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-7735
Mailing Address - Country:US
Mailing Address - Phone:989-350-0017
Mailing Address - Fax:
Practice Address - Street 1:312 S JAMES ST
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-1818
Practice Address - Country:US
Practice Address - Phone:989-348-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302034626183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist