Provider Demographics
NPI:1114352911
Name:DALLAS, AFUSAT (LPN)
Entity Type:Individual
Prefix:
First Name:AFUSAT
Middle Name:
Last Name:DALLAS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8950 ARNOLD
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-1528
Mailing Address - Country:US
Mailing Address - Phone:313-739-3025
Mailing Address - Fax:
Practice Address - Street 1:5840 N CANTON CENTER RD STE 212
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2614
Practice Address - Country:US
Practice Address - Phone:734-844-6533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703108850164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse