Healthcare Provider Details

I. General information

NPI: 1124393202
Provider Name (Legal Business Name): IMAN NP CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 08/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26771 W 12 MILE RD SUITE 101
SOUTHFIELD MI
48034-1539
US

IV. Provider business mailing address

26771 W 12 MILE RD SUITE 101
SOUTHFIELD MI
48034-1539
US

V. Phone/Fax

Practice location:
  • Phone: 248-595-8536
  • Fax: 248-809-2043
Mailing address:
  • Phone: 248-595-8536
  • Fax: 248-809-2043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State

VIII. Authorized Official

Name: VERONICA SHIVACHI-WILLIAMS
Title or Position: NURSE PRACTITIONER
Credential: NP-C
Phone: 248-595-8536