Provider Demographics
NPI:1053664102
Name:HERNDON, PATRICIA
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:HERNDON
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 1:33150 SCHOOLCRAFT RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1646
Mailing Address - Country:US
Mailing Address - Phone:248-581-6674
Mailing Address - Fax:734-943-6023
Practice Address - Street 1:33150 SCHOOLCRAFT RD
Practice Address - Street 2:SUITE 203
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-1646
Practice Address - Country:US
Practice Address - Phone:248-581-6674
Practice Address - Fax:734-943-6023
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI46-0748116343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)