Provider Demographics
NPI:1265310205
Name:MYKOLENKO, GREGORY P
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:P
Last Name:MYKOLENKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31630 BRETZ DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-5535
Mailing Address - Country:US
Mailing Address - Phone:586-939-9391
Mailing Address - Fax:
Practice Address - Street 1:31630 BRETZ DR
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-5535
Practice Address - Country:US
Practice Address - Phone:586-939-9391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-26
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide