Healthcare Provider Details

I. General information

NPI: 1962725556
Provider Name (Legal Business Name): ANN MARIE KUYKENDALL PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 03/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5777 W MAPLE RD STE 200
WEST BLOOMFIELD MI
48322-2271
US

IV. Provider business mailing address

5777 W MAPLE RD STE 200
WEST BLOOMFIELD MI
48322-2271
US

V. Phone/Fax

Practice location:
  • Phone: 248-932-9223
  • Fax: 248-932-8641
Mailing address:
  • Phone: 248-932-9223
  • Fax: 248-932-8641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601002554
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: