Healthcare Provider Details

I. General information

NPI: 1184343303
Provider Name (Legal Business Name): WARNER MYNTTI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13111 ALLEN RD
SOUTHGATE MI
48195-2216
US

IV. Provider business mailing address

4766 WASHTENAW AVE APT A8
ANN ARBOR MI
48108-1424
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7705
  • Fax:
Mailing address:
  • Phone: 231-679-2425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: