Healthcare Provider Details

I. General information

NPI: 1831962406
Provider Name (Legal Business Name): LAUREN CISLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37000 GRAND RIVER AVE STE 310
FARMINGTON HILLS MI
48335-2868
US

IV. Provider business mailing address

2153 LAKEVIEW DR APT 38
YPSILANTI MI
48198-6708
US

V. Phone/Fax

Practice location:
  • Phone: 248-536-2127
  • Fax:
Mailing address:
  • Phone: 734-558-2066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011939
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: