Provider Demographics
NPI:1780791954
Name:CECCANESE, KIM (NP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:CECCANESE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:MONACEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:ATTENTION: LYNDA THOMPSON
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-1108
Mailing Address - Country:US
Mailing Address - Phone:734-677-7400
Mailing Address - Fax:734-677-7407
Practice Address - Street 1:135 BARCLAY CIR
Practice Address - Street 2:SUITE 104
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4599
Practice Address - Country:US
Practice Address - Phone:248-853-7270
Practice Address - Fax:248-853-7230
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704150130363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4292496Medicaid
MI5008666430OtherBCBS
MI5008666430OtherBCBS
MI0N22810Medicare ID - Type Unspecified