Healthcare Provider Details

I. General information

NPI: 1699209205
Provider Name (Legal Business Name): JODI WACHOWIAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3007 N SAGINAW RD
MIDLAND MI
48640-4555
US

IV. Provider business mailing address

36 LAURIE CT LOT 129
ESSEXVILLE MI
48732-9409
US

V. Phone/Fax

Practice location:
  • Phone: 989-633-1400
  • Fax:
Mailing address:
  • Phone: 989-894-0021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703078235
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: