Provider Demographics
NPI:1225194038
Name:CHURCH, PATI PUTT (CUNP)
Entity Type:Individual
Prefix:MRS
First Name:PATI
Middle Name:PUTT
Last Name:CHURCH
Suffix:
Gender:F
Credentials:CUNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3621 SOUTH STATE STREET
Mailing Address - Street 2:700 KMS PLACE
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108
Mailing Address - Country:US
Mailing Address - Phone:734-936-2047
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DRIVE
Practice Address - Street 2:B1 FLOOR CANCER & GERIATRIC CENTER RECP C
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5913
Practice Address - Country:US
Practice Address - Phone:734-647-8903
Practice Address - Fax:734-647-8860
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704211868363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner