Healthcare Provider Details

I. General information

NPI: 1679104186
Provider Name (Legal Business Name): ANNABELLE VILLARREAL SLOTKA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6122 W PIERSON RD UNIT 1
FLUSHING MI
48433-3104
US

IV. Provider business mailing address

12416 WOLFBERRY CT
FENTON MI
48430-9683
US

V. Phone/Fax

Practice location:
  • Phone: 810-600-3399
  • Fax:
Mailing address:
  • Phone: 248-459-0323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704294180
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: