Healthcare Provider Details

I. General information

NPI: 1255973236
Provider Name (Legal Business Name): KAITLYN ROSE KOWALCZYK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAITLYN ROSE COON

II. Dates (important events)

Enumeration Date: 10/11/2019
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 PATIENT CARE DR STE A
LANSING MI
48911-4271
US

IV. Provider business mailing address

3955 PATIENT CARE DR STE A
LANSING MI
48911-4271
US

V. Phone/Fax

Practice location:
  • Phone: 517-374-7600
  • Fax: 855-495-5457
Mailing address:
  • Phone: 517-374-7600
  • Fax: 855-495-5457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704310971
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: