=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215516620
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HAILEY KRISTINE OLDS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2021
-----------------------------------------------------
Last Update Date | 06/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 EUREKA RD
-----------------------------------------------------
City | WYANDOTTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48192-6103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-282-2500
-----------------------------------------------------
Fax | 734-282-6397
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 151 SOUTHHALL LN STE 300
-----------------------------------------------------
City | MAITLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32751-7172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 4301513802
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------