Provider Demographics
NPI:1295596013
Name:MARDLIN, MCKENNA NICOLE (MS, ATC, EMT, OPE-C)
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:NICOLE
Last Name:MARDLIN
Suffix:
Gender:F
Credentials:MS, ATC, EMT, OPE-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1161 QUAIL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6075
Mailing Address - Country:US
Mailing Address - Phone:248-807-1577
Mailing Address - Fax:
Practice Address - Street 1:4001 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-3038
Practice Address - Country:US
Practice Address - Phone:313-623-2109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-18
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010031172255A2300X
MI2017040146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic