Healthcare Provider Details

I. General information

NPI: 1205342714
Provider Name (Legal Business Name): MARIA MELODY-PADIERNOS WOLFINBARGER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2017
Last Update Date: 02/12/2024
Certification Date: 02/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2600
  • Fax: 313-916-4460
Mailing address:
  • Phone: 313-916-2600
  • Fax: 313-916-4460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704261513
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: