Basic Information
| Provider Information | |||||||||
| NPI: | 1265635155 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GANGNIER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | MARIE REISS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REISS | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 43151 DALCOMA DR | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480386306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862868720 | ||||||||
| FaxNumber: | 8667906803 | ||||||||
| Practice Location | |||||||||
| Address1: | 2305 GENOA BUSINESS PARK DR | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481147004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103554300 | ||||||||
| FaxNumber: | 8103554967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| LastUpdateDate: | 04/08/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 5601005019 | MI | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.