Healthcare Provider Details

I. General information

NPI: 1043676513
Provider Name (Legal Business Name): DEBORAH YACKO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8033 E 10 MILE RD
CENTER LINE MI
48015-1427
US

IV. Provider business mailing address

8033 E 10 MILE RD
CENTER LINE MI
48015-1427
US

V. Phone/Fax

Practice location:
  • Phone: 586-756-6661
  • Fax: 586-756-6933
Mailing address:
  • Phone: 586-756-6661
  • Fax: 586-756-6933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703083162
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: