Healthcare Provider Details

I. General information

NPI: 1831508787
Provider Name (Legal Business Name): JIE QIU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2014
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34815 W MICHIGAN AVE
WAYNE MI
48184-1799
US

IV. Provider business mailing address

17366 HILLTOP VIEW DR
NORTHVILLE MI
48168-1878
US

V. Phone/Fax

Practice location:
  • Phone: 734-721-4739
  • Fax:
Mailing address:
  • Phone: 313-294-2941
  • Fax: 313-294-0437

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704240297
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: