Healthcare Provider Details

I. General information

NPI: 1619548641
Provider Name (Legal Business Name): MS. LYDIA KOWALESKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2021
Last Update Date: 07/09/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W GREENLAWN AVE STE 200
LANSING MI
48910-2889
US

IV. Provider business mailing address

8753 JASON RD
LAINGSBURG MI
48848-9227
US

V. Phone/Fax

Practice location:
  • Phone: 248-261-4792
  • Fax:
Mailing address:
  • Phone: 517-420-4197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: