Provider Demographics
NPI:1336487727
Name:MUSICK, MARY KATHRYN (CPNP-AC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:MUSICK
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:KATHRYN
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP-AC
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44199 DEQUINDRE RD STE 615
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1128
Practice Address - Country:US
Practice Address - Phone:248-964-9660
Practice Address - Fax:248-964-9665
Is Sole Proprietor?:No
Enumeration Date:2013-01-21
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704255022363L00000X, 363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704255022OtherNURSE PRACTITIONER LICENSE