Provider Demographics
NPI:1487700951
Name:JAGIELO, KATHY (NP)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:JAGIELO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2007
Mailing Address - Fax:810-743-1099
Practice Address - Street 1:1096 S BELSAY RD
Practice Address - Street 2:SUITE A
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1948
Practice Address - Country:US
Practice Address - Phone:810-742-6100
Practice Address - Fax:810-742-1742
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704146308363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4077828Medicaid
MIP13057Medicare UPIN
MIN16710001Medicare PIN