=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104486877
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN ALEXIS KALLIANTASIS RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/16/2019
-----------------------------------------------------
Last Update Date | 10/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22101 MOROSS RD
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48236-2148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-343-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 55537 TIMBERS EDGE DR
-----------------------------------------------------
City | SHELBY TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48316-5363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-688-7908
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WG0000X
-----------------------------------------------------
Taxonomy Name | General Practice Registered Nurse
-----------------------------------------------------
License Number | 4704309721
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 4704309721NSA190D3
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------