Provider Demographics
NPI:1598341406
Name:WALUKONIS, SAVANNAH L
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:L
Last Name:WALUKONIS
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 1:739 MEADOWLAKE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1591
Mailing Address - Country:US
Mailing Address - Phone:231-580-9284
Mailing Address - Fax:
Practice Address - Street 1:739 MEADOWLAKE RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-1591
Practice Address - Country:US
Practice Address - Phone:231-580-9284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-22
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704322636363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care