Provider Demographics
NPI:1114382728
Name:BASKERVILLE, LOLA
Entity Type:Individual
Prefix:
First Name:LOLA
Middle Name:
Last Name:BASKERVILLE
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 1:2766 W 11 MILE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-3033
Mailing Address - Country:US
Mailing Address - Phone:248-542-2424
Mailing Address - Fax:248-542-5621
Practice Address - Street 1:2766 W 11 MILE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-3033
Practice Address - Country:US
Practice Address - Phone:248-542-2424
Practice Address - Fax:248-542-5621
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-24
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704119887163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse