Healthcare Provider Details

I. General information

NPI: 1669232161
Provider Name (Legal Business Name): ALICE M DURHAM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 03/21/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 TOWNER ST
YPSILANTI MI
48198-5723
US

IV. Provider business mailing address

555 TOWNER ST
YPSILANTI MI
48198-5723
US

V. Phone/Fax

Practice location:
  • Phone: 734-544-3050
  • Fax: 734-544-6732
Mailing address:
  • Phone: 734-544-3050
  • Fax: 734-544-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number4704261175
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: