Healthcare Provider Details

I. General information

NPI: 1891556494
Provider Name (Legal Business Name): ELIZABETH ASHLEY KOTENKO DNP, AGPCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH ASHLEY UPDIKE DNP, AGPCNP

II. Dates (important events)

Enumeration Date: 01/22/2024
Last Update Date: 01/22/2024
Certification Date: 01/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46457 PEACH GROVE AVE
MACOMB MI
48044-4603
US

IV. Provider business mailing address

46457 PEACH GROVE AVE
MACOMB MI
48044-4603
US

V. Phone/Fax

Practice location:
  • Phone: 248-464-3746
  • Fax:
Mailing address:
  • Phone: 248-464-3746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704262821
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: