Provider Demographics
NPI:1659464808
Name:NAZARKO, LAURA LYNN (PT)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNN
Last Name:NAZARKO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-416-9100
Mailing Address - Fax:586-416-9103
Practice Address - Street 1:15520 19 MILE RD
Practice Address - Street 2:SUITE 450
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6333
Practice Address - Country:US
Practice Address - Phone:586-416-2000
Practice Address - Fax:586-416-2013
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010503225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI65-0-E0-1746-0OtherBCBS PROVIDER NUMBER
MIP19660001Medicare PIN