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General NPI Number Information
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NPI Number | 1649880329
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Entity Type | Individual
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Provider Name | DEDRA DELANE FORD NP-C
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Gender | Female
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Dates
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Enumeration Date | 08/06/2020
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Last Update Date | 01/13/2021
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Provider Practice Location Address
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Address Line | 22250 PROVIDENCE DR STE 202
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City | SOUTHFIELD
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State | MI
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Zip | 48075-6210
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Country | US
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Telephone | 248-849-7400
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Fax | 248-849-7401
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Provider Business Mailing Address
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Address Line | 22250 PROVIDENCE DR STE 202
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City | SOUTHFIELD
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State | MI
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Zip | 48075-6210
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Country | US
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Telephone | 248-849-7400
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Fax | 248-849-7401
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 4704286031
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License Number State | MI
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