Healthcare Provider Details

I. General information

NPI: 1942569827
Provider Name (Legal Business Name): JULIA MADELINE ELLISON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2012
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2653 SOUTH BLVD APT 138
AUBURN HILLS MI
48326-3576
US

IV. Provider business mailing address

2653 SOUTH BLVD APT 138
AUBURN HILLS MI
48326-3576
US

V. Phone/Fax

Practice location:
  • Phone: 248-636-3515
  • Fax:
Mailing address:
  • Phone: 248-636-3515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number246RP1900X
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: