Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 5101019063 | MI |
NPI | 1003110552 |
---|---|
Provider Name | Jennifer Burlingame |
First Address | Warren, MI 48088-6683 |
Second Address | Warren, MI 48088-6683 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/12/2010 |
Last Update Date | 27/12/2010 |