Healthcare Provider Details

I. General information

NPI: 1457821084
Provider Name (Legal Business Name): KIMBERLY L TRAVER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY LYNNE KOZLOWSKI NP

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 TOWN CENTER DR STE 106
TROY MI
48084-1744
US

IV. Provider business mailing address

130 TOWN CENTER DR STE 106
TROY MI
48084-1744
US

V. Phone/Fax

Practice location:
  • Phone: 248-619-3100
  • Fax: 248-619-9031
Mailing address:
  • Phone: 248-619-3100
  • Fax: 248-619-9031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704294157
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: