Healthcare Provider Details

I. General information

NPI: 1396163390
Provider Name (Legal Business Name): KYLEIGH NAISMITH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 OWEN RD STE A
FENTON MI
48430-3417
US

IV. Provider business mailing address

PO BOX 775316
CHICAGO IL
60677-5316
US

V. Phone/Fax

Practice location:
  • Phone: 810-496-2500
  • Fax: 810-629-0415
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101021319
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: