Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156F00000X | Technician/Technologist | MI |
NPI | 1144981754 |
---|---|
Provider Name | Mia Sanae Dandridge |
First Address | Livonia, MI 48154-5403 |
Second Address | Livonia, MI 48154-5403 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/01/2022 |
Last Update Date | 05/01/2022 |