Provider Demographics
NPI:1437701372
Name:KOTZAN, MARY RENEE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:RENEE
Last Name:KOTZAN
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 1:2700 SCENIC MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-8919
Mailing Address - Country:US
Mailing Address - Phone:248-875-3302
Mailing Address - Fax:
Practice Address - Street 1:882 OAKMAN BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-3710
Practice Address - Country:US
Practice Address - Phone:313-961-4890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704132402163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse