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General NPI Number Information
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NPI Number | 1679399604
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Entity Type | Individual
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Provider Name | LAURYN ALEXUS MCKENNEY
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Gender | Female
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Dates
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Enumeration Date | 11/25/2024
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Last Update Date | 11/25/2024
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Provider Practice Location Address
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Address Line | 674 GLYNN CT
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City | DETROIT
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State | MI
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Zip | 48202-1451
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Country | US
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Telephone | 313-707-0090
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Fax |
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Provider Business Mailing Address
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Address Line | 220 W CONGRESS ST # 1024
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City | DETROIT
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State | MI
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Zip | 48226-3289
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Country | US
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Telephone | 313-513-2400
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Fax |
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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 | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 4703121534
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License Number State | MI
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