Healthcare Provider Details

I. General information

NPI: 1427313121
Provider Name (Legal Business Name): INGRID L BLAIR RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 W GRAND BLVD
DETROIT MI
48208-1105
US

IV. Provider business mailing address

25850 BEECH CT
SOUTHFIELD MI
48033-2824
US

V. Phone/Fax

Practice location:
  • Phone: 313-961-3200
  • Fax:
Mailing address:
  • Phone: 810-874-3112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704262720
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704262720
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: