Healthcare Provider Details

I. General information

NPI: 1659970002
Provider Name (Legal Business Name): NECOLA SELENA TABLE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2020
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4909 E OUTER DR
DETROIT MI
48234-3446
US

IV. Provider business mailing address

4909 E OUTER DR
DETROIT MI
48234-3446
US

V. Phone/Fax

Practice location:
  • Phone: 313-366-2000
  • Fax: 313-447-1582
Mailing address:
  • Phone: 313-366-2000
  • Fax: 313-447-1582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704250204
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: