Healthcare Provider Details

I. General information

NPI: 1144724303
Provider Name (Legal Business Name): KANISHA WARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2018
Last Update Date: 03/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 FRANK LLOYD WRIGHT DR
ANN ARBOR MI
48105-9484
US

IV. Provider business mailing address

PO BOX 2275
BELLEVILLE MI
48112-2275
US

V. Phone/Fax

Practice location:
  • Phone: 734-930-7400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601001391
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: