Healthcare Provider Details

I. General information

NPI: 1003605353
Provider Name (Legal Business Name): WANDA ROCHELLE HURT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2025
Last Update Date: 05/03/2025
Certification Date: 05/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6609 YALE ST APT 327
WESTLAND MI
48185-2138
US

IV. Provider business mailing address

6609 YALE ST APT 327
WESTLAND MI
48185-2138
US

V. Phone/Fax

Practice location:
  • Phone: 734-516-0502
  • Fax:
Mailing address:
  • Phone: 313-439-2245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: