Healthcare Provider Details

I. General information

NPI: 1366245110
Provider Name (Legal Business Name): PENELOPE RAMPAZO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 W GRAND BLVD
DETROIT MI
48202-3046
US

IV. Provider business mailing address

1227 SUMMIT ST
LAPEER MI
48446-3919
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2454
  • Fax:
Mailing address:
  • Phone: 810-969-4546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601013352
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: