Provider Demographics
NPI:1225417587
Name:LOVE, AVIS COLLEEN (LPN)
Entity Type:Individual
Prefix:MS
First Name:AVIS
Middle Name:COLLEEN
Last Name:LOVE
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 1:1291 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-1741
Mailing Address - Country:US
Mailing Address - Phone:313-565-7831
Mailing Address - Fax:313-565-7831
Practice Address - Street 1:1291 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-1741
Practice Address - Country:US
Practice Address - Phone:313-565-7831
Practice Address - Fax:313-565-7831
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703053762164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI16OtherLPN