Healthcare Provider Details

I. General information

NPI: 1073196697
Provider Name (Legal Business Name): MS. HEATHER DAWN PREVOST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2021
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36555 26 MILE RD STE 1100
LENOX MI
48048-3186
US

IV. Provider business mailing address

36555 26 MILE RD
LENOX MI
48048-3185
US

V. Phone/Fax

Practice location:
  • Phone: 947-523-4010
  • Fax:
Mailing address:
  • Phone: 947-523-4010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704279946
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704279946
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF09210133
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number4704279946
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: