Provider Demographics
NPI:1376317412
Name:CERMAK, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CERMAK
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 1:3646 MOUNT ELLIOTT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2311
Mailing Address - Country:US
Mailing Address - Phone:313-671-1044
Mailing Address - Fax:
Practice Address - Street 1:14049 E 13 MILE RD STE 1
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-5876
Practice Address - Country:US
Practice Address - Phone:248-410-4997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704343232163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse