Provider Demographics
NPI:1225520919
Name:HARTWELL-KING, KATHLEEN M IV (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:HARTWELL-KING
Suffix:IV
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:BENDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:5777 W MAPLE RD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 HOLMES RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198
Practice Address - Country:US
Practice Address - Phone:734-218-0456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI470415667363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily