Provider Demographics
NPI:1003285859
Name:SCHRADER, JUSTINE
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:SCHRADER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7244 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-1903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1979 HOLLAND AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8639
Practice Address - Country:US
Practice Address - Phone:810-982-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2018-03-17
Deactivation Date:2018-02-06
Deactivation Code:
Reactivation Date:2018-02-23
Provider Licenses
StateLicense IDTaxonomies
MI4704278975363L00000X, 364SA2200X, 364SG0600X, 364SP2800X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
No364SP2800XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPerioperative