Healthcare Provider Details

I. General information

NPI: 1063135432
Provider Name (Legal Business Name): KRISTINE TRESTON KOWALEWSKY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 10/13/2022
Certification Date: 10/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9065 34TH RD
CADILLAC MI
49601
US

IV. Provider business mailing address

2360 BARBEAU DR
TRAVERSE CITY MI
49696-8940
US

V. Phone/Fax

Practice location:
  • Phone: 231-577-5017
  • Fax:
Mailing address:
  • Phone: 810-923-7595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704338235
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: