Provider Demographics
NPI:1578781795
Name:POE, ADDIE M (NURSE)
Entity Type:Individual
Prefix:MRS
First Name:ADDIE
Middle Name:M
Last Name:POE
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20053 SAINT MARYS ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2330
Mailing Address - Country:US
Mailing Address - Phone:313-653-5741
Mailing Address - Fax:313-653-5746
Practice Address - Street 1:4777 E OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-3241
Practice Address - Country:US
Practice Address - Phone:313-369-1960
Practice Address - Fax:313-369-1977
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703089489164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse