Healthcare Provider Details

I. General information

NPI: 1568964658
Provider Name (Legal Business Name): KRISTIN KOSS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2018
Last Update Date: 12/13/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44555 WOODWARD AVE
PONTIAC MI
48341
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DRIVE SUITE J2000
ANN ARBOR MI
48105
US

V. Phone/Fax

Practice location:
  • Phone: 248-858-6104
  • Fax: 248-839-6746
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704273147
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: