Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist |
NPI | 1124780796 |
---|---|
Provider Name | Elorie Lilah Derderian |
First Address | Lake Orion, MI 48360-1433 |
Second Address | Lake Orion, MI 48360-1433 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2021 |
Last Update Date | 11/10/2021 |