Healthcare Provider Details

I. General information

NPI: 1164676581
Provider Name (Legal Business Name): ASPEN STJOHN R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2008
Last Update Date: 11/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 ALLEN RD # 100
SOUTHGATE MI
48195-2216
US

IV. Provider business mailing address

13101 ALLEN RD # 100
SOUTHGATE MI
48195-2216
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7701
  • Fax: 734-287-4602
Mailing address:
  • Phone: 734-785-7701
  • Fax: 734-287-4602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704261781
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: