Healthcare Provider Details

I. General information

NPI: 1639665201
Provider Name (Legal Business Name): SALLY GRIBBEN-MOE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2018
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2689
US

IV. Provider business mailing address

24724 MELODY RD
WARREN MI
48089-4749
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-0450
  • Fax:
Mailing address:
  • Phone: 248-420-3248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704295388
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: