MEDICARE: MS. JONNIE M HAMILTON PNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	4704102288	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386648897
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JONNIE M HAMILTON PNP

Provider Business Mailing Address
First Line	:	18250 MARK TWAIN ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-2546
Country	:	US
Telephone Number	:	313-866-9973
Fax Number	:	313-866-5749

Provider Business Practice Location Address
First Line	:	2301 VAN DYKE ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48214-3958
Country	:	US
Telephone Number	:	313-866-9973
Fax Number	:	313-866-5749

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	12/20/2011

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