Healthcare Provider Details

I. General information

NPI: 1306217179
Provider Name (Legal Business Name): MANUELA JASMIN CAMARGO-RUELLE DNP,FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2015
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST STE 7B
DETROIT MI
48201-2153
US

IV. Provider business mailing address

400 MACK AVE
DETROIT MI
48201-2136
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-2554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704277161
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: