Healthcare Provider Details

I. General information

NPI: 1659054815
Provider Name (Legal Business Name): KAITLIN KIK FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2424 W WASHINGTON AVE STE 200
JACKSON MI
49203-1236
US

IV. Provider business mailing address

2424 W WASHINGTON AVE STE 200
JACKSON MI
49203-1236
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-4001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704347076
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: