Provider Demographics
NPI:1437399854
Name:KRAFT, KATHLEEN LOUISE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LOUISE
Last Name:KRAFT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15420 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6339
Mailing Address - Country:US
Mailing Address - Phone:586-226-7007
Mailing Address - Fax:
Practice Address - Street 1:15420 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6339
Practice Address - Country:US
Practice Address - Phone:586-226-7007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704202988363L00000X
NE112003363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner