Healthcare Provider Details

I. General information

NPI: 1114316163
Provider Name (Legal Business Name): JUDITH ANN OGREN NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25810 KELLY RD STE 3
ROSEVILLE MI
48066-4467
US

IV. Provider business mailing address

25810 KELLY RD STE 3
ROSEVILLE MI
48066-4467
US

V. Phone/Fax

Practice location:
  • Phone: 586-777-9724
  • Fax:
Mailing address:
  • Phone: 586-777-9724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704146117
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704146117
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: