Provider Demographics
NPI:1114422763
Name:BRICKERSON, TAMARA J
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:J
Last Name:BRICKERSON
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 1:12818 SUSSEX ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-2118
Mailing Address - Country:US
Mailing Address - Phone:313-712-6800
Mailing Address - Fax:
Practice Address - Street 1:12818 SUSSEX ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-2118
Practice Address - Country:US
Practice Address - Phone:313-712-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704260356163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse