Healthcare Provider Details

I. General information

NPI: 1871735563
Provider Name (Legal Business Name): VANESSA KONDZIOLKA NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2009
Last Update Date: 03/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16800 24 MILE RD SUITE 4
MACOMB MI
48042-2990
US

IV. Provider business mailing address

16800 24 MILE RD SUITE 4
MACOMB MI
48042-2990
US

V. Phone/Fax

Practice location:
  • Phone: 586-992-9970
  • Fax: 586-992-9972
Mailing address:
  • Phone: 586-992-9970
  • Fax: 586-992-9972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704244257
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: