Provider Demographics
NPI:1104486877
Name:KALLIANTASIS, LAUREN ALEXIS (RN)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:ALEXIS
Last Name:KALLIANTASIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55537 TIMBERS EDGE DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-5363
Mailing Address - Country:US
Mailing Address - Phone:248-688-7908
Mailing Address - Fax:
Practice Address - Street 1:22101 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2148
Practice Address - Country:US
Practice Address - Phone:313-343-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-16
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704309721163WG0000X
MI4704309721NSA190D3367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice