Healthcare Provider Details

I. General information

NPI: 1851388854
Provider Name (Legal Business Name): KRISTA LYNNE YEZBACK BC-FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 N CANTON CENTER RD
CANTON MI
48187-5097
US

IV. Provider business mailing address

3621 S STATE ST 700 KMS PLACE
ANN ARBOR MI
48108-1633
US

V. Phone/Fax

Practice location:
  • Phone: 734-884-5400
  • Fax: 734-844-5298
Mailing address:
  • Phone: 734-936-2047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704189915
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: