Healthcare Provider Details

I. General information

NPI: 1003144098
Provider Name (Legal Business Name): LORI SUE MITCHELL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LORI SUE HARRISON

II. Dates (important events)

Enumeration Date: 12/02/2009
Last Update Date: 12/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 ALLEN RD
SOUTHGATE MI
48195-2216
US

IV. Provider business mailing address

18640 HILLTOP DR
RIVERVIEW MI
48193-1801
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7731
  • Fax: 734-785-7731
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704149474
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: