Healthcare Provider Details

I. General information

NPI: 1538548433
Provider Name (Legal Business Name): TARA MACHLEIT LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 DEXTER TRL
STOCKBRIDGE MI
49285-9470
US

IV. Provider business mailing address

3930 DEXTER TRL
STOCKBRIDGE MI
49285-9470
US

V. Phone/Fax

Practice location:
  • Phone: 330-415-4983
  • Fax:
Mailing address:
  • Phone: 330-416-4983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number4703110627
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: