Healthcare Provider Details

I. General information

NPI: 1639675473
Provider Name (Legal Business Name): JUSTON N MANSFIELD NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 W 8 MILE RD
FERNDALE MI
48220-2100
US

IV. Provider business mailing address

1546 PEARSON ST
FERNDALE MI
48220-1648
US

V. Phone/Fax

Practice location:
  • Phone: 248-398-3200
  • Fax: 248-398-3200
Mailing address:
  • Phone: 248-721-7388
  • Fax: 313-543-6233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704283237NSA18453
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: