Healthcare Provider Details

I. General information

NPI: 1386775526
Provider Name (Legal Business Name): TERRA LEE CUSHMAN R.N., BSN., CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 W GRAND BLVD STE 800
DETROIT MI
48202-3141
US

IV. Provider business mailing address

12438 MEANDER
TECUMSEH ONTARIO
N8N4P3
CA

V. Phone/Fax

Practice location:
  • Phone: 313-916-7359
  • Fax: 313-916-9027
Mailing address:
  • Phone: 519-979-0658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number4704186479
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: