Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 4704314525 | MI |
NPI | 1003569310 |
---|---|
Provider Name | Lauren Koenig |
First Address | Berkley, MI 48072-3172 |
Second Address | Roseville, MI 48066-3901 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/01/2022 |
Last Update Date | 27/01/2022 |