Healthcare Provider Details

I. General information

NPI: 1033810619
Provider Name (Legal Business Name): COURTNEY NASTALLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 03/13/2023
Certification Date: 03/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 FULLER RD
ANN ARBOR MI
48105-2303
US

IV. Provider business mailing address

1018 PAGE AVE
JACKSON MI
49203-2036
US

V. Phone/Fax

Practice location:
  • Phone: 734-769-7100
  • Fax:
Mailing address:
  • Phone: 517-395-3638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303004849
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: