Provider Demographics
NPI:1043498462
Name:CONKLIN, EVELYN COLLEEN (MS-RN)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:COLLEEN
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:MS-RN
Other - Prefix:
Other - First Name:E.
Other - Middle Name:COLLEEN
Other - Last Name:CONKLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS-RN
Mailing Address - Street 1:43835 BRANDYWYNE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2158
Mailing Address - Country:US
Mailing Address - Phone:734-459-8991
Mailing Address - Fax:
Practice Address - Street 1:43835 BRANDYWYNE RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2158
Practice Address - Country:US
Practice Address - Phone:734-459-8991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704080542101Y00000X, 163WP0808X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health