Provider Demographics
NPI:1346631470
Name:FISHER, LACRETIA (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:LACRETIA
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:LUCRETIA
Other - Middle Name:
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1560 E MAPLE RD
Mailing Address - Street 2:SUITE 400-CREDENTIALING DEPARTMENT
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1138
Mailing Address - Country:US
Mailing Address - Phone:313-993-3434
Mailing Address - Fax:313-993-3421
Practice Address - Street 1:3901 CHRYSLER SERVICE DR
Practice Address - Street 2:TOLAN PARK
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2167
Practice Address - Country:US
Practice Address - Phone:313-993-3434
Practice Address - Fax:313-993-3421
Is Sole Proprietor?:No
Enumeration Date:2015-02-11
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704281509163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3434247Medicaid