Healthcare Provider Details

I. General information

NPI: 1609690106
Provider Name (Legal Business Name): LORINA DANIELLA MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44201 DEQUINDRE RD
TROY MI
48085-1117
US

IV. Provider business mailing address

15689 WILLIAMSBURG DR E
MACOMB MI
48044-2212
US

V. Phone/Fax

Practice location:
  • Phone: 248-964-5000
  • Fax:
Mailing address:
  • Phone: 586-747-9547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704341279
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: