Healthcare Provider Details

I. General information

NPI: 1053079707
Provider Name (Legal Business Name): ANGELENE ROSE KENNEDY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2021
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24230 KARIM BLVD STE 100
NOVI MI
48375-2960
US

IV. Provider business mailing address

28428 W 8 MILE RD UNIT C8
FARMINGTON HILLS MI
48336-5951
US

V. Phone/Fax

Practice location:
  • Phone: 248-745-4900
  • Fax:
Mailing address:
  • Phone: 734-560-6538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number4704309210
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: