Healthcare Provider Details

I. General information

NPI: 1578004941
Provider Name (Legal Business Name): KATHRYN IRENE IDZIKOWSKI FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2017
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 E 12 MILE RD
WARREN MI
48093
US

IV. Provider business mailing address

11800 E 12 MILE RD
WARREN MI
48093-3472
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-5059
  • Fax:
Mailing address:
  • Phone: 586-306-4304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704280994
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: