Healthcare Provider Details

I. General information

NPI: 1891815445
Provider Name (Legal Business Name): JEAN NYAMBIO CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 09/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4707 SAINT ANTOINE ST
DETROIT MI
48201-1427
US

IV. Provider business mailing address

PO BOX 67000 DEPT 203401
DETROIT MI
48267-2034
US

V. Phone/Fax

Practice location:
  • Phone: 952-442-9770
  • Fax:
Mailing address:
  • Phone: 952-442-9770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704256997
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number4704256997
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: