Provider Demographics
NPI:1043246564
Name:FAVOT, MARY JANE (NP)
Entity Type:Individual
Prefix:
First Name:MARY JANE
Middle Name:
Last Name:FAVOT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15400 MICHIGAN AVE
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3491
Mailing Address - Country:US
Mailing Address - Phone:313-584-3359
Mailing Address - Fax:313-584-1729
Practice Address - Street 1:15400 MICHIGAN AVE
Practice Address - Street 2:SUITE ONE
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3491
Practice Address - Country:US
Practice Address - Phone:313-584-3359
Practice Address - Fax:313-584-1729
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI109477363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology