Healthcare Provider Details

I. General information

NPI: 1225626948
Provider Name (Legal Business Name): MTT FNP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25140 AUSTIN DR
NEW BOSTON MI
48164-8907
US

IV. Provider business mailing address

25140 AUSTIN DR
NEW BOSTON MI
48164-8907
US

V. Phone/Fax

Practice location:
  • Phone: 313-461-5780
  • Fax:
Mailing address:
  • Phone: 313-461-5780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MOYA TARA TALLEY
Title or Position: ADMIN
Credential: FNP
Phone: 313-461-5780