Healthcare Provider Details

I. General information

NPI: 1265368948
Provider Name (Legal Business Name): AMANDA LYNN GERVASONI DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA LYNN ROBERTS

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28050 GRAND RIVER AVE
FARMINGTON HILLS MI
48336-5919
US

IV. Provider business mailing address

28050 GRAND RIVER AVE
FARMINGTON HILLS MI
48336-5919
US

V. Phone/Fax

Practice location:
  • Phone: 947-521-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number5951001628
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: