| NPI | 1962035402 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: MI 4704277919) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704277919) |
| Enumeration Date | 2020-02-12 |
| Last Update Date | 2023-04-24 |