Healthcare Provider Details

I. General information

NPI: 1114352911
Provider Name (Legal Business Name): AFUSAT DALLAS L.P.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2013
Last Update Date: 09/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5840 N CANTON CENTER RD STE 212
CANTON MI
48187-2614
US

IV. Provider business mailing address

8950 ARNOLD
REDFORD MI
48239-1528
US

V. Phone/Fax

Practice location:
  • Phone: 734-844-6533
  • Fax:
Mailing address:
  • Phone: 313-739-3025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703108850
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: