Healthcare Provider Details

I. General information

NPI: 1871391540
Provider Name (Legal Business Name): MARY LOUISE SEVERIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 W LIBERTY RD STE A
ANN ARBOR MI
48103-9794
US

IV. Provider business mailing address

8865 ARGONNE
GREGORY MI
48137-9650
US

V. Phone/Fax

Practice location:
  • Phone: 734-417-5233
  • Fax: 734-994-4322
Mailing address:
  • Phone: 734-417-5233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number470410293
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: