Healthcare Provider Details

I. General information

NPI: 1912504978
Provider Name (Legal Business Name): MARY MARGARET KRZYSTOWCZYK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2020
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 SIXTH ST
TRAVERSE CITY MI
49684-2300
US

IV. Provider business mailing address

1105 SIXTH ST
TRAVERSE CITY MI
49684-2300
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-5000
  • Fax:
Mailing address:
  • Phone: 231-935-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704301134
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAG01200132
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAG01200132
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: