Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1174160626 |
---|---|
Provider Name | Alicea Swann |
First Address | Bingham Farms, MI 48025-2454 |
Second Address | Bingham Farms, MI 48025-2454 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/12/2019 |
Last Update Date | 03/12/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0008185677 | (05) | MI |