Provider Demographics
NPI:1396756128
Name:KMAK, VALERIE ANNE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:ANNE
Last Name:KMAK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 VENDOME RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3348
Mailing Address - Country:US
Mailing Address - Phone:313-886-1948
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:4F
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-4380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704157115363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology