Provider Demographics
NPI:1902473390
Name:BAJOREK, KATHLEEN MARIE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:BAJOREK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4034 ELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-1134
Mailing Address - Country:US
Mailing Address - Phone:248-881-9382
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-05
Last Update Date:2021-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704307506364SG0600X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program