Healthcare Provider Details

I. General information

NPI: 1205428000
Provider Name (Legal Business Name): MS. KRISTINA KNECHTL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 09/08/2024
Certification Date: 09/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W 14 MILE RD
CLAWSON MI
48017-3100
US

IV. Provider business mailing address

555 W 14 MILE RD
CLAWSON MI
48017-3100
US

V. Phone/Fax

Practice location:
  • Phone: 248-655-1400
  • Fax:
Mailing address:
  • Phone: 248-655-1400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704343032
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: