Healthcare Provider Details

I. General information

NPI: 1417010315
Provider Name (Legal Business Name): DEANNA LATRISE FREEMAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 01/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 JOHN R ST STE 510
DETROIT MI
48201-2021
US

IV. Provider business mailing address

24321 TAMARACK CIR
SOUTHFIELD MI
48075-6182
US

V. Phone/Fax

Practice location:
  • Phone: 313-993-7777
  • Fax:
Mailing address:
  • Phone: 248-595-1054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704218153
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704218153
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: