Healthcare Provider Details

I. General information

NPI: 1013685734
Provider Name (Legal Business Name): MARY FRASER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24841 TERRA DEL MAR DR
NOVI MI
48374-2530
US

IV. Provider business mailing address

24841 TERRA DEL MAR DR
NOVI MI
48374-2530
US

V. Phone/Fax

Practice location:
  • Phone: 248-761-9053
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number4704201038
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: