Healthcare Provider Details

I. General information

NPI: 1548404510
Provider Name (Legal Business Name): MISS MARNIE LYNN FUERTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2009
Last Update Date: 04/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28000 DEQUINDRE RD
WARREN MI
48092-2468
US

IV. Provider business mailing address

RR # 1 WOODSLEE
WOODSLEE ONTARIO
N0R 1V0
CA

V. Phone/Fax

Practice location:
  • Phone: 248-967-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704228859
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: