Provider Demographics
NPI:1902975501
Name:KAITNER, ROSEANNE (NP)
Entity Type:Individual
Prefix:
First Name:ROSEANNE
Middle Name:
Last Name:KAITNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ROSEANNE
Other - Middle Name:
Other - Last Name:KUBIT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1860
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:4949 COOLIDGE HWY
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-1026
Practice Address - Country:US
Practice Address - Phone:248-655-5900
Practice Address - Fax:248-655-5901
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRK206961363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ05173Medicare UPIN