Healthcare Provider Details

I. General information

NPI: 1508210667
Provider Name (Legal Business Name): MARY ELIZABETH KOWNACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 JOHN R ST 7-BRUSH N, MAIL BOX 165
DETROIT MI
48201-2018
US

IV. Provider business mailing address

611 MADISON AVE APT B
CHARLOTTESVILLE VA
22903-2110
US

V. Phone/Fax

Practice location:
  • Phone: 313-993-4030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: