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General NPI Number Information
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NPI Number | 1285044081
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Entity Type | Individual
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Provider Name | TRACIE KENYON
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Gender | Female
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Dates
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Enumeration Date | 05/01/2014
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Last Update Date | 05/01/2014
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Provider Practice Location Address
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Address Line | 3883 E GRAND RIVER AVE
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City | HOWELL
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State | MI
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Zip | 48843-8564
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Country | US
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Telephone | 517-552-6610
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Fax | 517-552-6665
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Provider Business Mailing Address
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Address Line | 11619 RIDGE RD
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City | SOUTH LYON
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State | MI
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Zip | 48178-9319
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Country | US
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Telephone | 517-552-6610
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Fax | 517-552-6665
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1835P1200X
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Taxonomy Name | Pharmacotherapy Pharmacist
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License Number | 5302025428
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 1835P1200X
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Taxonomy Name | Pharmacotherapy Pharmacist
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License Number | PS39138
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License Number State | FL
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