Provider Demographics
NPI:1174501506
Name:KING, KATHLEEN WOJDA (NP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:WOJDA
Last Name:KING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 HARRINGTON BLVD.
Mailing Address - Street 2:DISEASE MANAGEMENT
Mailing Address - City:MT. CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2920
Mailing Address - Country:US
Mailing Address - Phone:586-493-8565
Mailing Address - Fax:586-493-8186
Practice Address - Street 1:1000 HARRINGTON ST
Practice Address - Street 2:DISEASE MANAGEMENT
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2920
Practice Address - Country:US
Practice Address - Phone:586-493-8565
Practice Address - Fax:586-493-8186
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704114606363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10-4586056Medicaid
MI10-4719985Medicaid
MI10-4719949Medicaid
MI10-4719958Medicaid
MI10-4719967Medicaid
MI10-4719976Medicaid
MI10-4719958Medicaid
MIS79601Medicare UPIN
MI10-4586056Medicaid