Healthcare Provider Details

I. General information

NPI: 1689769093
Provider Name (Legal Business Name): MARY KATHRYN GANO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 NORTH COUNTY LINE HWY
DEERFIELD MI
49238
US

IV. Provider business mailing address

345 NORTH COUNTY LINE HWY
DEERFIELD MI
49238
US

V. Phone/Fax

Practice location:
  • Phone: 517-447-4053
  • Fax:
Mailing address:
  • Phone: 517-447-4053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number47-04-198423
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: