Provider Demographics
NPI:1609628908
Name:BORNER, DAMITA
Entity Type:Individual
Prefix:
First Name:DAMITA
Middle Name:
Last Name:BORNER
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 1:39015 PRENTISS ST APT 206
Mailing Address - Street 2:
Mailing Address - City:HARRISON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-4317
Mailing Address - Country:US
Mailing Address - Phone:586-443-1818
Mailing Address - Fax:
Practice Address - Street 1:707 W MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2943
Practice Address - Country:US
Practice Address - Phone:313-498-3109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704300376163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse