Provider Demographics
NPI:1942439815
Name:LUSTIG, HEATHER LYNN (NP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:LUSTIG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LYNN
Other - Last Name:DECOVICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:6900 ORCHARD LAKE RD STE 204
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3425
Mailing Address - Country:US
Mailing Address - Phone:248-855-4177
Mailing Address - Fax:
Practice Address - Street 1:32255 NORTHWESTERN HWY STE 214
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1573
Practice Address - Country:US
Practice Address - Phone:248-855-5620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704224096363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology