Provider Demographics
NPI:1518501790
Name:STRUBLE, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:STRUBLE
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 1:50430 SCHOOL HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-5910
Mailing Address - Country:US
Mailing Address - Phone:734-748-1465
Mailing Address - Fax:
Practice Address - Street 1:50430 SCHOOL HOUSE RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-5910
Practice Address - Country:US
Practice Address - Phone:734-748-1465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI282334Medicaid