Healthcare Provider Details

I. General information

NPI: 1679743322
Provider Name (Legal Business Name): JUDY C WHEELER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28050 GRAND RIVER AVE
FARMINGTON HILLS MI
48336-5919
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 248-471-8000
  • Fax:
Mailing address:
  • Phone: 947-522-1862
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704115137
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704115137
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: