Healthcare Provider Details

I. General information

NPI: 1790680023
Provider Name (Legal Business Name): MAIA HUMBLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 LAWTON ST
DETROIT MI
48208-2500
US

IV. Provider business mailing address

37097 BRYNFORD DR
CLINTON TOWNSHIP MI
48036-2402
US

V. Phone/Fax

Practice location:
  • Phone: 313-361-6136
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703129261
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: