Healthcare Provider Details

I. General information

NPI: 1023800562
Provider Name (Legal Business Name): BURSHONDA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13217 FRAZHO RD
WARREN MI
48089-1302
US

IV. Provider business mailing address

13217 FRAZHO RD
WARREN MI
48089-1302
US

V. Phone/Fax

Practice location:
  • Phone: 313-977-7544
  • Fax:
Mailing address:
  • Phone: 313-977-7544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberOQLQ56
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: