Healthcare Provider Details

I. General information

NPI: 1962263970
Provider Name (Legal Business Name): CAMIRYN BRENT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRENT MIKEL LOPEZ

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W MILWAUKEE ST
DETROIT MI
48202-2943
US

IV. Provider business mailing address

707 W MILWAUKEE ST
DETROIT MI
48202-2943
US

V. Phone/Fax

Practice location:
  • Phone: 313-498-3091
  • Fax:
Mailing address:
  • Phone: 313-498-3091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number4704341467
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: