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General NPI Number Information
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NPI Number | 1629868260
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Entity Type | Individual
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Provider Name | MRS. DIEDRA LYNN MCCLERKIN
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Gender | Female
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Dates
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Enumeration Date | 05/07/2025
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Last Update Date | 05/07/2025
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Provider Practice Location Address
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Address Line | 5149 SAINT CLAIR ST
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City | DETROIT
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State | MI
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Zip | 48213-4300
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Country | US
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Telephone | 313-721-7215
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Fax |
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Provider Business Mailing Address
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Address Line | 42590 STEPNITZ DR
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City | CLINTON TOWNSHIP
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State | MI
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Zip | 48036-3161
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Country | US
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Telephone | 586-954-1838
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Fax | 586-649-2620
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 4703064653
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License Number State | MI
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