Provider Demographics
NPI:1720556335
Name:D'HAENE, KATELYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:D'HAENE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7125 ORCHARD LAKE RD
Mailing Address - Street 2:STE 100
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3616
Mailing Address - Country:US
Mailing Address - Phone:248-865-7444
Mailing Address - Fax:
Practice Address - Street 1:1280 E CAMPUS DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3803
Practice Address - Country:US
Practice Address - Phone:517-803-6285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
MI5601009593363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant