Healthcare Provider Details

I. General information

NPI: 1639703473
Provider Name (Legal Business Name): BRIAN LEDL DNP, APRN, AGPCNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5285 ANTHONY WAYNE DR
DETROIT MI
48202-3947
US

IV. Provider business mailing address

5200 ANTHONY WAYNE DR
DETROIT MI
48202-3945
US

V. Phone/Fax

Practice location:
  • Phone: 313-577-5041
  • Fax:
Mailing address:
  • Phone: 313-577-5041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1400X
TaxonomyCollege Health Registered Nurse
License Number4704276874
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number4704276874
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704276874
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: