Healthcare Provider Details

I. General information

NPI: 1689838468
Provider Name (Legal Business Name): IVYE L MOSS MLPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CITY OF DETROIT HEALTH DEPARTMENT 1151 TAYLOR ROOM 332
DETROIT MI
48202-1732
US

IV. Provider business mailing address

NORTHEAST HEALTH CENTER 5400 EAST 7 MILE ROOM 25
DETROIT MI
48234
US

V. Phone/Fax

Practice location:
  • Phone: 313-852-4291
  • Fax: 313-368-4694
Mailing address:
  • Phone: 313-852-4291
  • Fax: 313-368-4694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703063073
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: