Healthcare Provider Details

I. General information

NPI: 1295596013
Provider Name (Legal Business Name): MCKENNA NICOLE MARDLIN MS, ATC, EMT, OPE-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2024
Last Update Date: 06/19/2025
Certification Date: 06/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 W MCNICHOLS RD
DETROIT MI
48221-3038
US

IV. Provider business mailing address

1161 QUAIL RIDGE DR
OXFORD MI
48371-6075
US

V. Phone/Fax

Practice location:
  • Phone: 313-623-2109
  • Fax:
Mailing address:
  • Phone: 248-807-1577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number2017040
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601003117
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: