Healthcare Provider Details

I. General information

NPI: 1013268903
Provider Name (Legal Business Name): TICONNA D PURDLE N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7325 S EXCHANGE AVE
CHICAGO IL
60649-3407
US

IV. Provider business mailing address

21333 HAGGERTY RD SUITE 150
NOVI MI
48375-5510
US

V. Phone/Fax

Practice location:
  • Phone: 773-731-7300
  • Fax:
Mailing address:
  • Phone: 248-662-0250
  • Fax: 248-662-9844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209009555
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: