Healthcare Provider Details

I. General information

NPI: 1417447947
Provider Name (Legal Business Name): PAMELA ANN KACZOR FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 05/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28721 NORTHLINE RD
ROMULUS MI
48174
US

IV. Provider business mailing address

28721 NORTHLINE RD
ROMULUS MI
48174
US

V. Phone/Fax

Practice location:
  • Phone: 734-790-6306
  • Fax:
Mailing address:
  • Phone: 734-790-6306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704177676
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: