Provider Demographics
NPI:1639287790
Name:WARREN, JUDITH R (NP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:R
Last Name:WARREN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22101 LANCREST CT
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335
Mailing Address - Country:US
Mailing Address - Phone:248-473-5487
Mailing Address - Fax:734-427-8548
Practice Address - Street 1:28550 FIVE MILE ROAD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154
Practice Address - Country:US
Practice Address - Phone:734-427-8270
Practice Address - Fax:734-427-2135
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704081256363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJW081256OtherBLUE SHIELD
Q42615Medicare UPIN
MIP11300005Medicare ID - Type Unspecified