Healthcare Provider Details

I. General information

NPI: 1124422217
Provider Name (Legal Business Name): KYLE D. JENNINGS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44201 DEQUINDRE RD
TROY MI
48085-1117
US

IV. Provider business mailing address

750 STEPHENSON HWY
TROY MI
48083-1103
US

V. Phone/Fax

Practice location:
  • Phone: 248-267-5700
  • Fax: 248-267-5703
Mailing address:
  • Phone: 248-577-4995
  • Fax: 248-577-3526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704269646
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: