Healthcare Provider Details

I. General information

NPI: 1275909681
Provider Name (Legal Business Name): FONDA BREWER-WILLIAMS CERTIFIED HAIR LOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4255 MAR MOOR DR
LANSING MI
48917-1615
US

IV. Provider business mailing address

4255 MAR MOOR DR
LANSING MI
48917-1615
US

V. Phone/Fax

Practice location:
  • Phone: 517-410-2998
  • Fax:
Mailing address:
  • Phone: 517-410-2998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number47-4191902
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: