Healthcare Provider Details

I. General information

NPI: 1225564735
Provider Name (Legal Business Name): ASHLEY NICHOLE KOCHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2017
Last Update Date: 05/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N LEROY ST
FENTON MI
48430-5308
US

IV. Provider business mailing address

1001 N LEROY ST
FENTON MI
48430-5308
US

V. Phone/Fax

Practice location:
  • Phone: 810-750-1923
  • Fax: 810-714-4128
Mailing address:
  • Phone: 810-750-1923
  • Fax: 810-714-4128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303012917
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: