Provider Demographics
NPI:1982758298
Name:KZYONSEK, AMY EILEEN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:EILEEN
Last Name:KZYONSEK
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1357 NORTHWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:SARNIA
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N7S2K7
Mailing Address - Country:CA
Mailing Address - Phone:519-542-1170
Mailing Address - Fax:
Practice Address - Street 1:3111 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8127
Practice Address - Country:US
Practice Address - Phone:810-966-3728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704201226363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM97230007Medicare ID - Type Unspecified