Basic Information
| Provider Information | |||||||||
| NPI: | 1487162541 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KONGEAL | ||||||||
| FirstName: | LANCE | ||||||||
| MiddleName: | VALENTINE | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1312 CICOTTE AVE | ||||||||
| Address2: | |||||||||
| City: | LINCOLN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481461602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488437228 | ||||||||
| FaxNumber: | 2488437228 | ||||||||
| Practice Location | |||||||||
| Address1: | 33505 SCHOOLCRAFT RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347210200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2018 | ||||||||
| LastUpdateDate: | 01/11/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704279097 | MI | Y | Nursing Service Providers | Registered Nurse |
No ID Information.