Basic Information
| Provider Information | |||||||||
| NPI: | 1497392005 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IANNOTTI | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD STE 3D | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480333849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221848 | ||||||||
| FaxNumber: | 9475220307 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 BARCLAY CIR STE 150 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483074587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482995777 | ||||||||
| FaxNumber: | 2482996917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2019 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601009620 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.