Provider Demographics
NPI:1639242597
Name:KOCZENASZ, KRISTIE (APRN,BC)
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:KOCZENASZ
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 BOW POINTE DR
Mailing Address - Street 2:SUITE 280
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3198
Mailing Address - Country:US
Mailing Address - Phone:248-922-6833
Mailing Address - Fax:248-922-6831
Practice Address - Street 1:5701 BOW POINTE DR
Practice Address - Street 2:SUITE 280
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3198
Practice Address - Country:US
Practice Address - Phone:248-922-6833
Practice Address - Fax:248-922-6831
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704230739363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKK230739OtherBLUE CROSS BLUE SHIELD
MI5193349Medicaid
MICH3766OtherRAILROAD MEDICARE GROUP
MI5193358Medicaid
MI5193320Medicaid
MICH3766OtherRAILROAD MEDICARE GROUP
MIP34780034Medicare PIN
MI5193358Medicaid