Healthcare Provider Details

I. General information

NPI: 1013941921
Provider Name (Legal Business Name): MICHELE L MACK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18100 OAKWOOD BLVD SUITE 100
DEARBORN MI
48124-4085
US

IV. Provider business mailing address

18100 OAKWOOD BLVD SUITE 100
DEARBORN MI
48124-4085
US

V. Phone/Fax

Practice location:
  • Phone: 313-253-2000
  • Fax:
Mailing address:
  • Phone: 313-253-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704172231
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: