Provider Demographics
NPI:1083171151
Name:AVERY, SAUNDRA K (LPN, LMT)
Entity Type:Individual
Prefix:
First Name:SAUNDRA
Middle Name:K
Last Name:AVERY
Suffix:
Gender:F
Credentials:LPN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8399 HOLLY DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-4237
Mailing Address - Country:US
Mailing Address - Phone:734-218-0505
Mailing Address - Fax:
Practice Address - Street 1:8399 HOLLY DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-4237
Practice Address - Country:US
Practice Address - Phone:734-218-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703113427164W00000X
MI7501000228225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No164W00000XNursing Service ProvidersLicensed Practical Nurse