Provider Demographics
NPI:1043308398
Name:ETCHER, LUANN (NP)
Entity Type:Individual
Prefix:
First Name:LUANN
Middle Name:
Last Name:ETCHER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6149 N WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-7128
Mailing Address - Country:US
Mailing Address - Phone:734-728-2130
Mailing Address - Fax:734-728-2626
Practice Address - Street 1:6150 OAK TREE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-6917
Practice Address - Country:US
Practice Address - Phone:800-897-9177
Practice Address - Fax:800-470-8713
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704155261363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4583018Medicaid