Healthcare Provider Details

I. General information

NPI: 1942847116
Provider Name (Legal Business Name): DANA MARIE KOPACZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15125 22 MILE RD
SHELBY TOWNSHIP MI
48315-4406
US

IV. Provider business mailing address

9794 HILLCREST DR
PLYMOUTH MI
48170-3236
US

V. Phone/Fax

Practice location:
  • Phone: 586-532-0599
  • Fax:
Mailing address:
  • Phone: 248-990-2459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number4704300032
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: