Provider Demographics
NPI:1821430117
Name:CORRIVEAU, WENDY L (NP)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:L
Last Name:CORRIVEAU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1532
Mailing Address - Country:US
Mailing Address - Phone:248-921-0939
Mailing Address - Fax:
Practice Address - Street 1:5500 AUTO CLUB DR STE 350
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2779
Practice Address - Country:US
Practice Address - Phone:313-217-2000
Practice Address - Fax:313-217-2090
Is Sole Proprietor?:No
Enumeration Date:2013-07-27
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704282015363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health