Healthcare Provider Details

I. General information

NPI: 1215858865
Provider Name (Legal Business Name): PATRICE WILSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 CONNER ST STE 3015
DETROIT MI
48213-3806
US

IV. Provider business mailing address

5555 CONNER ST STE 3015
DETROIT MI
48213-3806
US

V. Phone/Fax

Practice location:
  • Phone: 313-324-2300
  • Fax:
Mailing address:
  • Phone: 313-324-2300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICE LAVON WILSON
Title or Position: CEO
Credential: RN
Phone: 313-324-2300