Healthcare Provider Details

I. General information

NPI: 1902857477
Provider Name (Legal Business Name): MARTHA ANNE KOHN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 11/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 W MICHIGAN AVE
JACKSON MI
49202-4158
US

IV. Provider business mailing address

DEPARTMENT 272801 PO BOX 67000
DETROIT MI
48267-2728
US

V. Phone/Fax

Practice location:
  • Phone: 517-796-6430
  • Fax: 517-784-6984
Mailing address:
  • Phone: 517-841-6913
  • Fax: 517-841-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704091620
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: