Healthcare Provider Details

I. General information

NPI: 1992127534
Provider Name (Legal Business Name): MRS. DONNA FELLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2014
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17141 RYAN RD
DETROIT MI
48212-1112
US

IV. Provider business mailing address

17141 RYAN RD
DETROIT MI
48212-1112
US

V. Phone/Fax

Practice location:
  • Phone: 313-733-4860
  • Fax:
Mailing address:
  • Phone: 313-733-4860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704085291
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: