Healthcare Provider Details

I. General information

NPI: 1124417332
Provider Name (Legal Business Name): TERRI BARD LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2766 11 MILE RD STE 2
BERKLEY MI
48072-3033
US

IV. Provider business mailing address

39040 NOTTINGHAM DR
ROMULUS MI
48174-6305
US

V. Phone/Fax

Practice location:
  • Phone: 248-542-2424
  • Fax: 248-542-5621
Mailing address:
  • Phone: 248-747-1757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703099185
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: