Healthcare Provider Details

I. General information

NPI: 1932076676
Provider Name (Legal Business Name): CAILYNN KOTZKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2025
Last Update Date: 10/18/2025
Certification Date: 10/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16001 W 9 MILE RD
SOUTHFIELD MI
48075-4818
US

IV. Provider business mailing address

25316 COLLINGWOOD ST
ROSEVILLE MI
48066-5707
US

V. Phone/Fax

Practice location:
  • Phone: 248-849-3331
  • Fax:
Mailing address:
  • Phone: 517-940-2545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704348917
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: