Provider Demographics
NPI:1215596820
Name:HART, DEANNA
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:HART
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 1:1428 S LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1437
Mailing Address - Country:US
Mailing Address - Phone:248-693-0543
Mailing Address - Fax:248-630-4301
Practice Address - Street 1:1428 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1437
Practice Address - Country:US
Practice Address - Phone:248-693-0543
Practice Address - Fax:248-630-4301
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704295183176B00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife