Healthcare Provider Details

I. General information

NPI: 1770456345
Provider Name (Legal Business Name): AUDREY MICHELLE MCDONALD FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 E 13 MILE RD # 200
WARREN MI
48093-3093
US

IV. Provider business mailing address

28253 NORWOOD AVE
WARREN MI
48092-5628
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-1810
  • Fax:
Mailing address:
  • Phone: 616-570-8584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704354250
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: