Healthcare Provider Details

I. General information

NPI: 1043498462
Provider Name (Legal Business Name): EVELYN COLLEEN CONKLIN MS-RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: E. COLLEEN CONKLIN MS-RN

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43835 BRANDYWYNE RD
CANTON MI
48187-2158
US

IV. Provider business mailing address

43835 BRANDYWYNE RD
CANTON MI
48187-2158
US

V. Phone/Fax

Practice location:
  • Phone: 734-459-8991
  • Fax:
Mailing address:
  • Phone: 734-459-8991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number4704080542
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704080542
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number4704080542
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: