Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1255096822 |
---|---|
Provider Name | Krystal Coughlin |
First Address | Livonia, MI 48154 |
Second Address | Livonia, MI 48154 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/11/2021 |
Last Update Date | 07/12/2021 |