Provider Demographics
NPI:1891556494
Name:KOTENKO, ELIZABETH ASHLEY (DNP, AGPCNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ASHLEY
Last Name:KOTENKO
Suffix:
Gender:F
Credentials:DNP, AGPCNP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ASHLEY
Other - Last Name:UPDIKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP, AGPCNP
Mailing Address - Street 1:46457 PEACH GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-4603
Mailing Address - Country:US
Mailing Address - Phone:248-464-3746
Mailing Address - Fax:
Practice Address - Street 1:46457 PEACH GROVE AVE
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-4603
Practice Address - Country:US
Practice Address - Phone:248-464-3746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704262821363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care