Healthcare Provider Details

I. General information

NPI: 1396756128
Provider Name (Legal Business Name): VALERIE ANNE KMAK NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST 4F
DETROIT MI
48201-2153
US

IV. Provider business mailing address

231 VENDOME RD
GROSSE POINTE FARMS MI
48236-3348
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-4380
  • Fax:
Mailing address:
  • Phone: 313-886-1948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number4704157115
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: