Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | 4704122237 | MI |
NPI | 1063456689 |
---|---|
Provider Name | Donna Jean Carrico |
First Address | Royal Oak, MI 48073-6712 |
Second Address | Royal Oak, MI 48073-6712 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0F31819 | BCBS (01) | MI |
4673438 | (05) | MI |
P24587 | (02) | MI |