Healthcare Provider Details

I. General information

NPI: 1730431917
Provider Name (Legal Business Name): KYLEE GATZKE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2012
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7985 MACKINAW TRL
CADILLAC MI
49601-8111
US

IV. Provider business mailing address

PO BOX 533
GRAYLING MI
49738-0533
US

V. Phone/Fax

Practice location:
  • Phone: 231-876-6200
  • Fax: 231-779-5290
Mailing address:
  • Phone: 231-876-7857
  • Fax: 231-876-7176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704266159
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: