Healthcare Provider Details

I. General information

NPI: 1720720410
Provider Name (Legal Business Name): MS. KRYSTINA RENEE-STARR CHILDRESS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 06/27/2023
Certification Date: 06/26/2023
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

405 W. GREEWLAWN AVE. SUITE 200
LANSING MI
48910
US

V. Phone/Fax

Practice location:
  • Phone: 248-221-2945
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number230013109650307
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: