Provider Demographics
NPI:1568908960
Name:DRAKE, COURTNEY LYNN (PA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYNN
Last Name:DRAKE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LYNN
Other - Last Name:DISCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:943 BERNIE LN
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-3484
Mailing Address - Country:US
Mailing Address - Phone:248-790-0627
Mailing Address - Fax:
Practice Address - Street 1:1521 GULL RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048
Practice Address - Country:US
Practice Address - Phone:269-226-4834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008757363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant