Individual
KELLY JOAN KOUSTAS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
751 E GRAND BLVD, DETROIT, MI 48207-2529
(313) 995-0523
Mailing address
24616 NOTRE DAME, DEARBORN, MI 48124
(313) 995-0523
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
4703110676
MI
Other
Enumeration date
09/21/2015
Last updated
09/21/2015
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