Healthcare Provider Details

I. General information

NPI: 1609123348
Provider Name (Legal Business Name): GRACE ALLEN GULLETT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2012
Last Update Date: 08/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13901 E JEFFERSON AVE
DETROIT MI
48215-2720
US

IV. Provider business mailing address

13901 E JEFFERSON AVE 7900 KERCHEVAL
DETROIT MI
48215-2720
US

V. Phone/Fax

Practice location:
  • Phone: 313-921-5500
  • Fax:
Mailing address:
  • Phone: 313-921-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704100180
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: