Provider Demographics
NPI:1902045594
Name:RUTHERFORD, LAJUANE E (RN)
Entity Type:Individual
Prefix:
First Name:LAJUANE
Middle Name:E
Last Name:RUTHERFORD
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15801 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3543
Mailing Address - Country:US
Mailing Address - Phone:248-414-5405
Mailing Address - Fax:248-414-5407
Practice Address - Street 1:15801 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3543
Practice Address - Country:US
Practice Address - Phone:248-414-5405
Practice Address - Fax:248-414-5407
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILR00251713207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5255236Medicaid