Healthcare Provider Details

I. General information

NPI: 1033773478
Provider Name (Legal Business Name): KRYSTA LIN PACIOCCO ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13400 W OUTER DR
DETROIT MI
48239-1309
US

IV. Provider business mailing address

13400 W OUTER DR
DETROIT MI
48239-1309
US

V. Phone/Fax

Practice location:
  • Phone: 313-324-8180
  • Fax: 313-324-8186
Mailing address:
  • Phone: 313-324-8180
  • Fax: 313-324-8186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number60909562
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704272375
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: