Healthcare Provider Details

I. General information

NPI: 1912555681
Provider Name (Legal Business Name): ISABELLA GRACE SNYDER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1462 CLIFTON RD NE
ATLANTA GA
30322-0001
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 248-534-7327
  • Fax:
Mailing address:
  • Phone: 313-874-4806
  • Fax: 313-876-1305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601013060
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: