Healthcare Provider Details

I. General information

NPI: 1992411581
Provider Name (Legal Business Name): TIFFANY SUSAN KOWALSKI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY SUSAN HART

II. Dates (important events)

Enumeration Date: 01/26/2023
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6210 W MAIN ST
KALAMAZOO MI
49009-8925
US

IV. Provider business mailing address

6210 W MAIN ST
KALAMAZOO MI
49009-8925
US

V. Phone/Fax

Practice location:
  • Phone: 269-286-7030
  • Fax: 269-286-7031
Mailing address:
  • Phone: 269-286-7030
  • Fax: 269-286-7031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704288605
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: