Healthcare Provider Details

I. General information

NPI: 1871683177
Provider Name (Legal Business Name): CLAUDE WARD LAUDERBACH JR. FNP-C, RN, DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2006
Last Update Date: 11/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36200 SCHOOLCRAFT RD
LIVONIA MI
48150-1253
US

IV. Provider business mailing address

41553 FAWN TRL
NOVI MI
48375-4817
US

V. Phone/Fax

Practice location:
  • Phone: 734-432-5482
  • Fax:
Mailing address:
  • Phone: 810-923-7490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4734328692
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number4734328692
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704128692NSA17450
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: