Healthcare Provider Details

I. General information

NPI: 1609632256
Provider Name (Legal Business Name): MRS. PENSRI P GELETKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2024
Last Update Date: 11/24/2024
Certification Date: 11/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15150 FORT ST
SOUTHGATE MI
48195-1302
US

IV. Provider business mailing address

15150 FORT ST
SOUTHGATE MI
48195-1302
US

V. Phone/Fax

Practice location:
  • Phone: 734-282-4800
  • Fax: 734-282-9302
Mailing address:
  • Phone: 734-282-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704299683NSA2403O
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: