Healthcare Provider Details

I. General information

NPI: 1902374986
Provider Name (Legal Business Name): THERESA OWUSU-ANSAH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 11/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26206 W 12 MILE RD STE 302
SOUTHFIELD MI
48034-8501
US

IV. Provider business mailing address

26206 W 12 MILE RD STE 302
SOUTHFIELD MI
48034-8501
US

V. Phone/Fax

Practice location:
  • Phone: 248-440-6090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704254603
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: