Provider Demographics
NPI:1457821597
Name:KIECKER, DARASOWAN ROJEPH-LIV
Entity Type:Individual
Prefix:MRS
First Name:DARASOWAN
Middle Name:ROJEPH-LIV
Last Name:KIECKER
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 1:13711 COMMERCE RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48380-1317
Mailing Address - Country:US
Mailing Address - Phone:248-470-5811
Mailing Address - Fax:
Practice Address - Street 1:18101 OAKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4089
Practice Address - Country:US
Practice Address - Phone:313-593-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-02
Last Update Date:2018-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704262339363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner