Provider Demographics
NPI:1255076634
Name:MCDONALD, KAMRYN LANE
Entity type:Individual
Prefix:
First Name:KAMRYN
Middle Name:LANE
Last Name:MCDONALD
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 1:101 CURRY AVE UNIT 210
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-4230
Mailing Address - Country:US
Mailing Address - Phone:810-869-5892
Mailing Address - Fax:
Practice Address - Street 1:101 CURRY AVE UNIT 210
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-4230
Practice Address - Country:US
Practice Address - Phone:810-869-5892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-01
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4704311771367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program