Healthcare Provider Details

I. General information

NPI: 1073962908
Provider Name (Legal Business Name): EMILY JO MORTENSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2016
Last Update Date: 06/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 S INDUSTRIAL HWY STE 75
ANN ARBOR MI
48104-6796
US

IV. Provider business mailing address

1321 SAINT JAMES PL
CHELSEA MI
48118-1171
US

V. Phone/Fax

Practice location:
  • Phone: 734-477-7298
  • Fax:
Mailing address:
  • Phone: 315-345-5989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number4704288456
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: