Provider Demographics
NPI:1578807715
Name:NETTLES, DORREAN MICHAEL (CERTIFICATE)
Entity Type:Individual
Prefix:
First Name:DORREAN
Middle Name:MICHAEL
Last Name:NETTLES
Suffix:
Gender:M
Credentials:CERTIFICATE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18971 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2908
Mailing Address - Country:US
Mailing Address - Phone:313-837-4748
Mailing Address - Fax:313-837-3772
Practice Address - Street 1:18971 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2908
Practice Address - Country:US
Practice Address - Phone:313-837-4748
Practice Address - Fax:313-837-3772
Is Sole Proprietor?:No
Enumeration Date:2012-11-10
Last Update Date:2012-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI225700000OtherMASSAGE THERAPIST
MI193200000XOtherMULTI SPECIALITY GROUP